


LIBRARY OF CONGRESS. 



"Ct(MW> 

Shelf..k>.ofo. 



UNITED STATES OF AMERICA. 



C H OLERA. 



CHOLERA: 



ITS ORIGIN, HISTORY, CAUSATION, SYMP- 
TOMS, LESIONS, PREVENTION, 
AND TREATMENT. 



BY 



ALFRED STILLE, M. D., LL.D., 

Professor Emeritus of the Theory and Practice of Medicine in 
the University of Pennsylvania. 



IP 



V 




PHILADELPHIA: 

LEA BROTHERS & CO. 

1885. 




X) 



Entered according to Act of Congress, in the year 1885, by 

LEA BROTHERS & CO., 

in the Office of the Librarian of Congress, at Washington. All rights reserved. 



Westcott & Thomson, 
Stereotyptrs and Electrotypers, Philada. 



PREFACE. 



The interest awakened in the public and in the 
medical profession by the possibility of the advent of 
cholera during the coming summer has led to the pub- 
lication of this treatise. The subject has always had 
a peculiar attraction for the author as a teacher and 
writer, and also because he had the painful advantage 
of studying it in two epidemics. The occurrence of 
cholera during 1884 in Egypt and Southern Europe 
has led to a renewed investigation of its nature, the 
chief outcome of which has been the theory formed 
by Dr. Koch and others regarding the material germ 
of the disease. While declining to accept the doc- 
trines of these physicians as demonstrated, the author 
seeks to exhibit the specific nature of cholera by evi- 
dence drawn from its origin and mode of propaga- 
tion ; to disabuse the medical profession of the erro- 
neous notioi? that the disease ever originates de novo ; 
to maintain the necessity of " quarantine," not in the 
literal but in the official sense of that word ; to point 

5 



6 PREFACE. 

out the channels through which cholera may be dif- 
fused ; and to describe the measures which experience 
has sanctioned to prevent its dissemination and cure 
those who are attacked by it. For these ends he 
has spared no pains to prepare a complete but 
compendious history of the disease as it occurred at 
different periods and in various countries, while the 
points most insisted upon are those which relate to 
its prevention and treatment. 

Philadelphia, May, 1885. 



CONTENTS. 



PAGE 

Definition of Cholera . 13 

History 13 

Cholera morbus of Greeks 

and Romans 14 

Ancient Asiatic cholera, 

descriptions of ... . 15 

Its prevalence in India . 16 
Extension to China and 

Japan 17 

" " Persia and Russia 18 

" " Europe 19 

" " America .... 19 

American epidemic of 1832 19 

Epidemic of 1845 .... 22 

" 1853 •... 23 

« " 1864, 1866-67 2 4 

" 1873 .... 25 

" 1881-83. . . 26 

" " 1884 .... 29 

" at Toulon, 1884 . 29 

" " Marseilles, " . . 30 

" in Italy, " . . 31 

Etiology 33 

Source and progress . . 34 

Influence of temperature . 35 

" " local causes 35, 38 
Water the chief vehicle of 

the poison 36 

Comparison with typhoid 

fever 39 

Its cause specific ..'••" 39 



PAGE 

Etiology — 

Fomites 40 

Illustrations of its communi- 
cability 41-58 

Symptomatology 60 

Mild types 62 

Cholerine 63 

Grave types 63 

" Cholera asphyxia "... 65 
Decline and convales- 
cence 67 

Complications and Sequels 58 

Eruptions on the skin. . . 68 

Temperature 70 

State of the skin .... 71 

Pulse and heart 72 

Condition of the veins . . 73 

Vomiting 74 

Stools 77 

Urine 78 

Cramps 79 

Morbid Anatomy and Path- 
ology 81 

Post-mortem spasms ... 82 

Dryness of the tissues . . 85 

Stomach 85 

Intestine 86 

Bacteria 90 

Other abdominal lesions . 95 

Nervous centres 97 

Lungs 97 

7 



CONTENTS. 



PAGE 

Morbid Anatomy and Path- 
ology — 

Heart 98 

Blood 98 

Theories discussed .... 100 

Diagnosis 106 

From cholera morbus ... 106 

" irritant poisoning . . 1 1 1 

Prognosis 113 

Mortality 1 14 

Prevention 117 

Quarantine 117 

Local sanitation 124 

Chemical disinfectants . . 125 
Rules for preventing chol- 
era 126 

Diet 130 



PAGE 

Treatment 131 

Antizymotics ...... 1 32 

Comparative results of treat- 
ment 136 

Rational treatment . . 136-145 

Venesection 145 

Ipecacuanha 146 

Calomel 147 

Stimulants 151 

Opiates 152 

Chloroform ; camphor ; 

acids .- . . 154 

Intravenous injection . . . 155 

Warm baths 158 

Cold affusions and drinks . 159 

Antiseptics 160 

Fanciful remedies .... 15 1 



CHOLERA. 



Definition. — Cholera is an epidemic disease, charac- 
terized by the transudation of serum into the stomach 
and bowels, and usually by the profuse discharge by 
vomiting and purging of a liquid resembling rice- 
water, followed by a tendency to collapse. It is en- 
demic in India, but has been conveyed thence to 
almost every part of the world. 

Synonyms. — Cholera algida, C. asiatica, C. asphyxia, 
C. maligna, C. spasmodica. In English it is generally 
spoken of as Asiatic cholera. 



HISTORY. 

It is sometimes stated that Hippocrates, Galen, 
Celsus, and the Greek, Roman, and Arabian medical 
writers generally record " the fact of the presence of 
cholera in the various countries in which they lived " 
(Macnamara). Nothing could be more contrary to the 
truth. All of these writers describe "cholera morbus" 
in nearly identical terms ; they all include bilious dis- 
charges among its symptoms, and no one of them 
speaks of it as a mortal or even as an epidemic dis- 
ease. (Compare, especially, Celsus, Aretaeus, Caelius 

2 13 



14 CHOLERA. 

Aurelianus,- and Paulus y£gineta.) Their description 
of sporadic cholera morbus is very precise. For ex- 
ample, Caelius Aurelianus says : " Cholericam passio- 
nem aiunt aliqui nominatam a fluore fellis, per os et 
ventrem effecto." 1 Many modern writers have also at- 
tempted to identify the " cholera " described by Aretaeus 
with the East Indian disease ; and if the enumeration 
he gives of the spasms, coldness, sweating, syncope, 
etc. were alone considered, the identification would be 
complete. But he also notes as prominent symptoms 
the vomiting of intensely yellow bile, and stools of a 
similar description. He particularly notes that if the 
disease tends to death black bile is voided upward and 
downward. And he adds that children are more liable 
to the disease than any other persons. 2 Now, the ab- 
sence of bile from the vomit and stools is the most 
distinctive feature of Asiatic cholera, and its presence 
in them, along with the other symptoms mentioned by 
Aretaeus, is equally characteristic of sporadic cholera, 
cholera morbus, or cholera nostras, as it is variously 
called. This confusion of two diseases essentially 
different from each other by reason of the specific 
cause which generates the one, and the variety of non- 
specific causes that give rise to the other, has led many 
otherwise respectable writers upon cholera into an error 
that taints all their communications upon the subject. 
And not merely such as relate to ancient epidemics, 
for they have swept sometimes into the category of 
" cholera " a variety of affections other than cholera 
morbus ; but in all of them, without exception, are to 

1 Acut. Morb., lib. iii. cap. xix. 

2 Works, Sydenham Soc. ed., p. 274. 



HISTORY. 15 

be found the two symptoms which belong to cholera 
morbus, and not to cholera — viz. vomiting and purging 
of bile — and, in addition, a lower rate of mortality 
than epidemic Asiatic cholera ever produced. Un- 
doubtedly, cholera morbus in its advanced stages is 
occasionally attended with watery or serous discharges ; 
but when this phenomenon is observed, it is only as an 
exceptional occurrence. 

Asiatic epidemic cholera is a very different disease. 
It seems to have been known in India from a very 
remote period, but no detailed account of it was pub- 
lished until the beginning of the sixteenth century. 
During that century many successive descriptions of 
the disease exhibited its extreme violence and mortal- 
ity. It is believed to have occurred repeatedly, if not 
annually, in the same localities down to the present 
time. The following account of its symptoms has 
come down to us : " This dolour struck on the stom- 
ach ; so grievous was the throe, and of so bad a sort, 
that the very worst kind of poison seemed to be taking 
effect, as proved by vomiting, with excessive thirst for 
water accompanying it, as if the stomach were parched 
up, and by the cramps that were fixed in the sinews of 
the joints and in the soles of the feet, with pain so ex- 
treme that the sufferer seemed at the point of death. 
The eyes were dimmed to the sense, and the nails of 
the hands and feet black and curved. For this disease 
none of our physicians found a cure. The patient 
barely lived the day — or, at most, the night — through, 
in such sort that of one hundred attacked scarcely ten 
escaped. So great was the mortality that the bells 
tolled all day long." This graphic description was 



J 6 CHOLERA. 

prepared by the Portuguese physicians at Goa in 

I543- 

The invasion of India by the Portuguese, and after- 
ward by the English, contributed to spread the disease 
throughout the Peninsula, partly by military occupation 
and partly through commercial channels, by which it 
was also carried to the islands in the Indian Ocean. 
It prevailed in Batavia in 1629. Bontius, the cele- 
brated naturalist, witnessed its ravages in that island, 
and prepared a description of the disease, in which, 
however, he introduces bilious vomiting and purging 
as characteristic of it, and so leads to the conclusion 
that he confounded cholera and cholera morbus, as so 
many later writers have done. Indeed, he distinctly 
assigns as its cause the extreme summer heat and ex- 
cessive indulgence in eating fruit. Between 1768 and 
1790 numerous epidemics of cholera occurred. About 
the former date no less than 60,000 persons are said 
to have perished near Pondicherry, and in 1783 it is 
reckoned that 20,000 victims to the disease fell in a 
single week during the religious gathering at the sa- 
cred city of Hurdwar, where, as will be seen hereafter, 
it became in later years more fatal still. The English 
armies extended their conquests in Hindostan, and es- 
tablished commerce between that country and Western 
Asia and Europe, and by the year 1 8 17 opened new 
channels of communication in every direction, both 
within and beyond the Peninsula. Along them the 
disease was carried ; it invaded Ceylon and the Bur- 
mese empire, and extended to Batavia, Java, and China 
on the east. In An. Epitome of the Reports of the Med- 
ical Officers of the Chinese Imperial Maritime Customs 



HISTORY. 17 

Service, from 1871 to 188*2, etc., compiled and arranged 
by Surgeon-General C. A. Gordon, M. D., C. B., Lon- 
don, 1884, it is stated that cholera has been known in 
China from time immemorial. But, judging by the 
account furnished of its causes and symptoms, the dis- 
ease described by the older Chinese authors was prob- 
ably not epidemic cholera, but cholera morbus. The 
former disease became known in China about 1669, 
and again prevailed in 1761 and 1769. On each occa- 
sion it was introduced from India. At the same time 
that it began to spread from the latter country toward 
the north-west — viz. in 18 17 — it was also carried in 
a north-easterly direction to China. In 1820 it ap- 
peared at Canton, and reached Pekin the following 
year. Similar incursions took place in 1826, and also 
from 1840 to 1843, when they seem to have ceased 
until 1858, after which the disease prevailed an- 
nually for ten years. It was then again suspended, 
and did not revive until 1877, in which year and in 
subsequent years it prevailed to a greater or less 
degree. 

The East Indian epidemics of the present century 
do not appear to have reached Japan until two years 
after they had invaded China — viz. in 1821-22; but if 
the Japanese chronicles have been correctly interpreted, 
an epidemic of cholera occurred in 17 18 in the city of 
Yedo, " the mortality from which exceeded 80,000 a 
month. The dead were so numerous that their inter- 
ment was impossible, and their bodies were consigned 
to the adjoining bay." In 1854, Japan was severely 
affected by cholera, said to have been imported by the 

U. S. frigate Mississippi ; after which there was no re- 

2 * 



1 8 CHOLERA. 

currence of the disease until 1877, when it was intro- 
duced by vessels from China. The recorded cases 
amounted to upward of 12,000, of which rather more 
than one-half were fatal. 

The history of cholera in China and Japan abun- 
dantly illustrates the principles or laws maintained in 
this essay, and confirms the general statement that 
cholera is one of the most communicable of dis- 
eases. 

The disease advanced westward to Persia in 1821. 
In that year also it was carried from Arabia into 
Africa, and at various later periods penetrated more 
and more deeply into the Dark Continent, always fol- 
lowing- the track of pilgrims returning from Mecca, 
the routes of armies engaged in war, or those of 
trading caravans. 1 

In these cases, as in others elsewhere, the spontane- 
ous origin of the disease has been assumed by certain 
writers, but at every stage of its progress careful inves- 
tigation led uniformly to the conclusion that it was 
propagated directly or indirectly from pre-existent 
cases of cholera. From Persia it moved northward 
as far as the shores of the Caspian Sea, and westward 
to the Levant in 1823, and there for a time its ravages 
were stayed. Meanwhile, it prevailed at various places 
throughout Hindostan, and, assuming a greater degree 
of violence in 1826, it advanced steadily in a north- 
western direction across Afghanistan and Persia in the 
following year. In 1829 it reached Orenburg, to the 
north of the Caspian Sea, and was speedily conveyed 
into the interior of the Russian empire, where it raged 

1 Christie, Cholera Epidemics in Africa, 1876. 



HISTORY. 19 

with great violence in 1830. In 1831 it prevailed at 
Mecca among the pilgrims, who had brought it from 
India, and so virulently that one-half of them are com- 
puted to have perished. Hence it speedily passed with 
returning pilgrims to Alexandria and Constantinople, 
and was carried to St. Petersburg, to Sweden, to Ham- 
burg, and other places in Northern continental Europe. 
From Hamburg and other seaports it was conveyed to 
commercial towns on the eastern coast of England, 
whence it extended to Edinburgh in the north and 
London in the south. 

In 1832 cholera prevailed in France, and within the 
year caused 120,000 deaths, 7000 of which occurred in 
Paris in the space of eighteen days. In the spring and 
summer of that year it was reproduced in England, 
and extended to Ireland. From Liverpool, Cork, 
Limerick, and Dublin five vessels filled with emi- 
grants sailed for Quebec, Canada, and they, together, 
lost 179 passengers by cholera during the voyage. 

The immediate results of this importation and first 
appearance of cholera on the American continent are 
described by Dr. Peters as follows : "All these ships 
and their passengers were quarantined at Grosse Isle, 
a few miles below Quebec. On June 7th the St. Law- 
rence steamer Voyageur conveyed a load of these emi- 
grants and their baggage, some to Quebec, but the 
majority to Montreal on the 10th. The first cases of 
cholera occurred in emigrant boarding-houses in Que- 
bec on the 8th, and the same pest-steamboat, the 
Voyageur, landed persons dead and dying of cholera 
at Montreal, a distance of two hundred miles, in less 
than thirty hours. Over this long distance, thickly 



20 CHOLERA. 

inhabited on both shores of the St. Lawrence, cholera 
made a single leap, without infecting a single village 
or a single house between the two cities, with the 
following exceptions : A man picked up a mattress 
thrown from the Voyageur, and he and his wife died 
of cholera ; another man, fishing on the St. Lawrence, 
was requested to bury a dead man from the Voyageur, 
and he and his wife and nephew died. The captain of 
a passing boat requested an Indian to bury a man from 
on board ; this man and five other Indians were at- 
tacked and died. The town of Three Rivers, halfway 
between Quebec and Montreal, forbade steamers to 
land, and escaped for a long time. From Montreal 
the great influx of emigrants were forwarded away, by 
the Emigrant Society, as fast as they arrived, and by 
them the pestilence was sown at each stopping-place. 
Kingston, Toronto, and Niagara soon became affected. 
In the end, over 4000 persons died of cholera in Mont- 
real, and more than an equal number in Quebec. The 
epidemic reached Detroit in the same way, .... and 
continued west along the Great Lakes, until in Sep- 
tember it reached our military posts on the Upper 

Mississippi Fort Dearborn, near Chicago, was 

temporarily reoccupied in 1832, and it was here that 
epidemic cholera displayed its most fatal effects among 
our troops. Out of 1000 men, over 200 cases were 
admitted into hospitals in the course of seven or eight 

days When these troops again marched for the 

Mississippi, they appeared in perfect health, yet the 
cholera broke out again on the way, and when the 
command reached the Mississippi it had been as fatal 
as it had been at Fort Dearborn." 



HISTOR Y. 2 1 

We may here for a moment interrupt the narrative 
of the progress of the disease to note the mode of its 
dissemination — i. e. by communication, direct or indi- 
rect, between the sick and the well. The records of 
this earliest of the American epidemics are full of illus- 
trative examples of its communicability, and from them 
we select only two or three. The invasion of Detroit 
has been referred to. The disease was introduced into 
that city by the United States troops on board the 
steamboat Henry Clay. The first case on the vessel 
was a soldier of intemperate habits, who died after an 
illness of seven hours. Others were soon taken ill. 
The vessel was ordered away, but on the following 
day two persons in the town who had been employed 
to communicate with the boat were attacked with the 
disease, and one of them died, and on the subsequent 
days other cases occurred. 

In October, 1832, the brig Amelia, with one hundred 
and eight persons on board, sailed from New York, 
where cholera was prevailing, for New Orleans. On 
the sixth day out the disease appeared on board. 
Later, the brig was stranded on Folly Island, ten miles 
from Charleston, S. C, and in a day or two afterward 
the disease began to spread among the inhabitants of 
the island. The persons employed about the wreck 
were the first and most severely attacked, and the 
wreckers in charge of the vessel lost six of their num- 
ber. Before the Amelia went ashore there had never 
been a case of cholera within two hundred miles of 
Folly Island. In July, 1832, at Oneida Castle, twenty- 
three miles west of Utica, N. Y., an Indian was hired 
by the captain of a passing canal-boat to bury a man 



22 CHOLERA. 

who had died of cholera on board. He procured 
other Indians to assist him. He was immediately 
seized with cholera, and died ; and five other Indians 
were taken, all of whom died. No other cases oc- 
curred. 1 

Meanwhile, an emigrant-ship with cholera on board 
reached New York, whence the disease spread up the 
Hudson River, and was also carried southwardly to 
Philadelphia and the West. The mortality in New 
York City from this epidemic is stated at 3500. In 
1833 the disease broke out in the cities of Havana and 
Matanzas in Cuba, and is said to have destroyed one- 
tenth of the entire population. Hence it was carried 
to Mexican and American towns on the Gulf of Mex- 
ico, and up the Mississippi and Ohio as far as the 
western border of Pennsylvania. In the following year 
it was again introduced at the port of Quebec by a 
vessel filled with emigrants, of whom many had died 
during the passage. It prevailed in Canada and the 
State of New York and spread over the whole country 
in 1835 and 1836. In the former of these two years it 
was confined to several Southern cities, whither it was 
brought, as on a former occasion, directly from Cuba. 
It then gradually subsided, and at last disappeared for 
the space of nearly ten years. 

But in 1845 it was known to be advancing on its 
former path, which it steadily pursued, and entered 
England in October, 1848, at Sunderland, the very town 
at which it first appeared in 1 83 1 . " During the second 
epidemic in Europe, in 1848, two vessels sailed from 

1 Bernard M. Byrne, M. D., An Essay to prove the contagious nature 
of Malignant Cholera (Baltimore and Philadelphia, 1833). 



HISTORY. 23 

Havre, where cholera prevailed — one, the New York, 
for New York, and the other, the Swanton, for New 
Orleans. Both contained large numbers of German 
emigrants. On one vessel the cholera appeared when 
it was sixteen days out, with fourteen deaths ; on the 
other, in twenty-six days, with thirteen deaths. The 
New York arrived at Staten Island Dec. 2, 1848, and 
a severe epidemic broke out, but was confined to the 
quarantine-grounds. ■ The Swanton arrived at New 
Orleans Dec. nth; no quarantine was instituted, and 
in two days its sick were taken into the Charity Hos- 
pital. This was the beginning of a severe epidemic, 
which increased in power all winter, till in June, 1849, 
2500 died of it in New Orleans. December 20, 1848, 
it reached Memphis by steamboat from New Orleans, 
and for twenty-five days was confined to the landing- 
place of the former city, whence it afterward spread. 
In the spring it was carried to St. Louis and Cin- 
cinnati and the whole Mississippi Valley. In Oc- 
tober it reached Sacramento, Cal., by means of over- 
land emigrants, and, almost at the same time, San 
Francisco, by the U. S. steamer Northerner from Pan- 
ama. The Chinese of California suffered most severely" 
(Peters). In April, 1849, cholera reappeared in the 
public stores at the quarantine-station, Staten Island, 
N. Y., and in the city of New York, where it was fatal 
to 5000 persons. 

A pause now took place in the ravages of the dis- 
ease which lasted until 1853. In that year it destroyed 
no less than 1 1 ,000 persons in the Persian city of 
Teheran. At Messina its victims numbered 12,000, 
in France 114,000, and in England about 16,000. In 



24 CHOLERA. 

1854 it was introduced by emigrant-ships into New 
York, causing a mortality of 2000 persons, and was 
carried to Philadelphia, where its victims numbered 
500. It extended to many towns in New England, 
and westward along the great channels of emigration. 
In Montreal the deaths were 1300, and in the then 
small town of Detroit, 1000. 

After an interval of quiescence longer than any pre- 
vious one the cholera again broke out among the pil- 
grims to Mecca in December, 1864. It appeared in 
Alexandria during May, 1865, and thence was carried 
to many parts of Europe, and from them to North 
America and the West Indies. " It was at Malta, 
Smyrna, and Constantinople before the end of June, 
and appeared in Spain and Italy and at Marseilles 
during July. Spreading somewhat widely during the 
next two months, it was at Southampton on September 
17, and on November 3 at New York" (Buchanan). 
The period of exemption above referred to included 
that of the Civil War in the United States, when, if 
ever, the local causes which have been erroneously 
assigned to the disease existed in all their forms and 
in the most intense degree. It was only when its 
specific germs were once more imported that cholera 
began to prevail again. Official records show that in 
1866 it was introduced from Europe into Halifax, N. S., 
the city of New York, and the military posts of New 
York harbor. Thence it was carried in troop-ships to 
various Southern ports, from which its progress could 
be traced to Texas and other Gulf States, and to the 
towns on the Mississippi and Missouri Rivers. From 
New York, also, the disease travelled westward to Cin- 



HISTORY. 25 

cinnati and the U. S. barracks at Newport, on the op- 
posite side of the Ohio River, whence it advanced in a 
south-westerly direction to meet the trail that, coming 
from the South, followed the great rivers of the Missis- 
sippi Valley. During the summer of 1867 cholera 
again prevailed, although less fatally, at most of the 
points, especially of the Mississippi Valley, which had 
been invaded the previous year, and some cases oc- 
curred at the military posts around New York in re- 
cruits who had shortly before arrived from places in 
the West where cholera prevailed. Thus did the dis- 
ease complete the circuit of the United States. 

Meanwhile, cholera prevailed to a greater or less 
extent in the east of Europe between 1865 and 1874. 
After the latter date it seems to have been confined to 
Syria, Arabia, and the African shore of the Mediterra- 
nean. In 1877-78 it existed to a limited extent among 
the pilgrims at Mecca; since then, until 1884, it was 
unknown in Europe. The latest appearance of cholera 
in the United States was in 1873, when it occurred at 
three points far distant from one another. It was in- 
troduced in the effects of immigrants. The vessels 
that brought them were in a perfect sanitary condition. 
The passengers themselves were healthy, and remained 
so after landing and until they reached the distant 
points of Carthage, Ohio, Crow River, Minn., and 
Yankton, Dak., where their goods were unpacked. 
At each place, " within twenty -four hours after the 
poison-particles were liberated, the first cases of the 
disease appeared, and the unfortunates were almost 
literally swept from the face of the earth " (E. Mc- 
Clellan). 



26 CHOLERA. 

A steamer from Bankok (Siam), where cholera was 
prevalent, arrived in 1 88 1 at Hoihow (China). It landed 
270 passengers. Soon afterward cholera broke out and 
was fatal to at least 400 persons, causing about one 
death in every three houses. It was remarked that 
the Cantonese who dwelt there were less affected than 
the natives, and their exemption was attributed to their 
more cleanly habits of living, especially in the use of 
water. 1 

In 1 88 1 cholera was brought from Hindostan to 
Arabia by pilgrims on their way to Mecca, where it 
soon afterward broke out and caused the death of 
about 8000 persons. In the following year several 
vessels from Bombay evaded the quarantine and ar- 
rived at Djeddah, the port of Mecca, and the pilgrims 
on reaching the latter city disseminated the disease. 
The unusually small number of persons who were 
there at the time, and their prompt dispersion before 
the danger, limited the mortality, and gradually cases 
of cholera ceased to appear. In 1882, the English at 
that time carrying on war in Egypt, very rigid sanitary 
precautions against the importation of cholera were 
enacted and successfully enforced, but in the following 
year, the same urgent necessity no longer command- 
ing, they were considerably relaxed. At the end of 
June, 1883, the cholera made its appearance at Dami- 
etta (at one of the mouths of the Nile), and soon after- 
ward at Rosetta, Port Said, and Mansourah. During 
July it spread to various places in direct communica- 
tion with those named. At Cairo it was peculiarly 
fatal, and on July 20th it was reported to have caused 

1 Aldridge, Times and Gazette, January, 1883, p. 18. 



HISTOR Y. 27 

600 deaths. For several days the daily mortality 
varied between 500 and 600. The disease prevailed 
somewhat in Alexandria during the height of the epi- 
demic, and near the end of October it was fatal to 
numerous European residents of that city, and some 
deaths occurred in the British army of occupation. 
In all Egypt, during the week ending Aug. 13th, the 
total mortality is said to have been 5000, but in the 
following week it fell to 2000. It is estimated that 
from the 22d of June to the 1st of September, 1883, 
the cholera destroyed at least 50,000 lives. The germ 
of this epidemic has not been accurately determined. 
Some regard it as a survival of the cholera of the pre- 
vious year — a supposition which is at least plausible 
and sufficient; but certain "sanitarians" have attrib- 
uted the outbreak to the ordinary causes of disease in- 
tensified by the civil war which had recently devastated 
Egypt. It is sufficient here to say that while such 
causes have in all ages generated typhus and typhoid 
fevers and dysentery, they never produced cholera. 
Some, more unwise than judicious, declared that the 
Egyptian disease of 1883 was not cholera. It is al- 
leged, on the one hand, that several -East Indian mer- 
chants from Bombay arrived at Damietta on June 18th, 
or three days before the disease was recognized in that 
city. It is also said that a stoker from on board an 
English steamer from Bombay introduced the cholera 
into Damietta. But the judgment of Surgeon-General 
Murray carries with it greater weight. 1 He is of the 
opinion that the Egyptian epidemic of 1883 was simply 
a revival of the Arabian epidemic of 1882.' He shows 

1 Times and Gazette, Feb., 1884, p. 209. 



28 CHOLERA. 

that cholera existed in several villages on the Damietta 
branch of the Nile in the latter part of May and dur- 
ing June, and that it broke out in the capital itself, 
during a fair which had lasted for eight days, on the 
22d of June, and was spread by the people on their 
return from Damietta to their villages. This, adds 
Mr. Murray, " is a literal transcript of the accounts of 
many of the severe epidemics that have raged over 
India." Dr. Peters describes with more detail the 
mode of origin and extension of this epidemic. 1 At 
Damietta and Port Said at least 15,000 people con- 
gregated, in addition to the 35,000 inhabitants, to 
attend a great fair. The barbers who shave and pre- 
pare the dead are the first registrars of vital statistics 
in many Egyptian towns, and the principal barber of 
Damietta was among the first to die of cholera; and 
hence the earliest records of deaths were lost. The 
water-supply of Damietta is obtained chiefly from a 
canal connecting two branches of the Nile. Mosques 
and many houses are on the banks of this canal, and 
their drainage goes into it. Every mosque has a pub- 
lic privy, and also a tank for the ablution which Mo- 
hammedans must practise before entering a holy 
place. There was, of course, great choleraic water- 
contamination, and a sudden outburst of cholera 
took place. Only when the strangers had fled from 
Damietta, panic-stricken, was a rigid quarantine estab- 
lished and a cordon put around the town " to keep 
everybody in and let no one go out, neither food, 
nor medicines, nor physicians, nor supplies of any 
kind." 

1 Med. Record, xxvii. 288. 



HIS TOR Y. 29 

It appears from M. Proust's narrative 1 that the Otto- 
man government had already, as early as April, noti- 
fied the government of Egypt that certain Indo-Javan- 
ese pilgrims were on their way to Mecca, and that 
they ought not to be allowed to land without quaran- 
tine. The French delegate to the sanitary council also 
begged that those of the pilgrims who reached Suez 
without previous quarantine should be isolated and 
kept under surveillance for three days. But owing to 
the opposition of the English delegates these measures 
were not duly enforced, the council did not meet again, 
and no protective system was adopted. 

About the end of June, 1884, it was announced by 
telegraph that an outbreak of cholera had taken place 
at Toulon, the great naval entrepot of France upon 
the Mediterranean, and soon afterward a similar an- 
nouncement was made of the appearance of the disease 
in the neighboring city of Marseilles. The infection 
was alleged to have been brought from China to 
Toulon in a transport vessel, La Sarthe, whose com- 
mander was reported to have committed suicide, owing 
to mental distress caused by his relation to the disaster. 
Drs. Brouardel and Proust, however, who were deputed 
by the French government to investigate the matter, 
reported to the Academy of Medicine that no blame 
could be attached to that unfortunate vessel, and that 
the first case of cholera occurred at Toulon June 14th, 
and the second on the following day, on board the 
Montebello, a ship that had been lying in port for 
fifteen months. But Dr. Koch, so well known by his 
investigations into the causation of cholera, is reported 

1 Le Cholera, 1 883. 
3* 



30 CHOLERA. 

to have spoken as follows upon this point : " I think 
I may say that, considering the precautions taken by 
the naval authorities, cholera was imported on some 
merchant-ship, probably English. They do not scru- 
ple on English vessels to hide deaths which occur on 
voyages or to falsify logs." 1 

An ungovernable panic seized upon the inhabitants 
of Toulon and Marseilles, and 6000 persons are re- 
ported to have quitted the former city. On the 22d 
of June a boy attending a grammar-school in Toulon 
died of cholera, after which the disease rapidly became 
epidemic. The commissioners were unable to deter- 
mine how the disease was introduced among the civil 
population, but they distinctly traced its dissemination 
by the sick, as in the following instance : " Two cases 
of cholera occurred at La Valette, a healthy village 
four miles distant from Toulon, in which a laborer 
coming from the latter place had died of cholera a few 
days before. As the two persons referred to had not 
for several months gone to Toulon, they apparently 
had contracted the disease from the first patient who 
died at La Valette." 

During the first week in July it was reported that 
eight or ten deaths occurred daily in the navy-yards 
of Toulon and in the town ; at the naval hospital 
there were sixty-two cholera patients. On the 6th 
of that month nine deaths from cholera took place at 
Toulon and sixteen at Marseilles, besides twenty cases 
that were carried to the hospital. For the week ending 
July 22d there were reported 175 deaths from cholera 
at Toulon and 338 at Marseilles, while the disease ex- 

1 Med. News, xlv. 84. 



HISTOR Y. 31 

tended to several neighboring places, and some cases 
of it occurred at Aries and Lyons. In all between 
800 and 900 fatal cases occurred in Toulon, and 1700 
in Marseilles. A steamer from Marseilles, which ar- 
rived at Liverpool July 18th, is said to have had two 
deaths from cholera during the voyage. 

A despatch from Marseilles of July 29th gives the 
number of deaths from cholera to that date as 1147, 
and another despatch of August 2d states the total 
mortality at 1248. From the commencement of the 
epidemic the inhabitants of the two cities in which the 
disease prevailed were seized with a panic, and every 
one who was able to escape fled from them. When, 
later, the victims of the disease had become more 
numerous, the inhabitants of other places refused to 
receive the fugitives. It is said that the people of a 
village near Beziers, headed by the mayor, drove off 
and stoned the refugees from Marseilles. No doubt, 
however, the disease was more or less disseminated by 
such persons in France, and also in Italy, for on July 
30th eight deaths from cholera were reported, and on 
August 2d twenty-seven cases, with twelve deaths, 
were said to have occurred at two villages in Italy. A 
little later the disease broke out in the southern prov- 
inces, and Naples and Spezia appear to have suffered 
most severely. The total number of deaths in the for- 
mer city is reported to have been 6842, and the high- 
est daily mortality 365. About the same time the 
disease prevailed in Genoa, and produced at least 1 168 
cases and 617 deaths; and the total number of fatal 
cases in Italy was about 10,000. The port of Huelva 
in Spain was also declared to be infected, and the 



32 CHOLERA. 

ports of Cadiz and Agamonte were suspected of 
being so ; but the disease was confined to the 
south-eastern coast-line. From July 30th the number 
of deaths from cholera in Toulon and Marseilles began 
to decline, and by August 2d had so nearly ceased in 
the latter city that no deaths from it were reported. 
The people are said to have returned in great num- 
bers, and the streets were assuming their normal 
aspect of gayety, and, according to the despatches, 
"physicians believed that the cholera would disap- 
pear from the city in a few days." The grounds of 
such a belief are not apparent, especially while the 
city was being filled again with its self-exiled popu- 
lation. Indeed, this increase of subjects was imme- 
diately followed by an increase in the number of deaths 
from cholera, which also occupied a wider area both in 
France and Italy. Under date of August 9th it was 
reported by telegraph that " the English cholera had 
appeared in several districts of Lancashire, and is mak- 
ing considerable headway. The number of persons 
stricken with it exceeds two hundred, and five deaths 
have so far occurred." The nature of this epidemic is 
open to question. 

The action of the authorities in various countries 
demonstrates the widespread belief in the communi- 
cability of cholera by the sick to the well. At a 
meeting of the Cabinet, held at Washington July 18th, 
a proclamation was authorized, and subsequently pub- 
lished by the President, enjoining vigilance and a strict 
performance of duty on all customs and health officers, 
and the examination at sea of all vessels from ports 
where infectious or contagious diseases prevailed at 



ETIOLOGY. 33 

the time of their sailing. About the same date the 
governments of nearly all European countries adopted 
measures to prevent the introduction of cholera by 
persons or merchandise. Not only were quarantine 
regulations at seaports applied as strictly as possible, 
but even the mountain-passes and other highways 
were watched to prevent the passage of infected per- 
sons. Indeed, so stringent were the sanitary regulations 
that travel and commerce were greatly interfered with, 
and in some places suspended altogether. On the other 
hand, the noxious and absurd practice of fumigating trav- 
ellers with burning sulphur was generally abandoned. 

According to a telegram dated Berlin, July 30th, 
" Dr. Koch had addressed his report on the epidemic 
to Prince Bismarck. He criticises severely the want 
of precaution shown by the English government in 
taking measures to prevent the spread of the epidemic. 
Should the cholera appear in England, Dr. Koch ad- 
vises that the strictest measures should be adopted 
against all vessels sailing from England." 



ETIOLOGY. 

The essential cause of cholera is unknown, unless 
the investigations of Koch, described below, may have 
revealed it. Its secondary causes, or the conditions of 
its dissemination, are better understood. Some general 
propositions concerning them will here be laid down, 
and illustrated so far as the argument requires and the 
available space will allow. 



34 CHOLERA. 

Cholera is endemic in no other country than India, 
and more particularly in Bengal. When it has oc- 
curred elsewhere it has invariably been carried from 
India. At the cholera conference held at Berlin in 
1884 a question was distinctly formulated, thus : "Is 
cholera generated by a specific infectious material 
which comes from India only ?" Professor Virchow 
remarked that there could scarcely be a discussion of 
this question in Germany ; at least, he did not know 
that any noteworthy attack upon the truth of this 
proposition had been made in Germany in the last 
decade. No dissenting opinion was expressed. The 
cholera-poison has been imagined to be of an aerial 
nature, but its diffusion has no relation whatever to 
the velocity or the direction of the wind. In no in- 
stance whatever has its rate of progress exceeded that 
of man on land or water, nor has it ever taken a di- 
rection different from that of commercial or military 
movements. On land it has usually crept from place 
to place, and if sometimes it has seemed to leap across 
wide spaces, and even seas and oceans, it has never 
invaded any inland town or seaport without having 
been brought thither from a point already affected with 
the disease. Nor, having once entered an inland or 
seaboard town, does it spread equally therein in all di- 
rections, but prevails chiefly in the quarter immedi- 
ately surrounding the place of its entrance. If appro- 
priate sanitary measures are enforced, it is sometimes 
confined to that quarter, and in the case of quarantine- 
stations it has repeatedly been prevented from extend- 
ing beyond them. This statement may be illustrated 
by the fact that of fourteen epidemics of cholera at 



ETIOLOGY. 35 

Staten Island, the quarantine-station of New York, all 
but four were prevented from reaching that city. 1 
When the disease does overleap the barrier opposed to 
it, its origin and subsequent course can usually be 
traced. 

' A high atmospheric temperature is everywhere asso- 
ciated with the prevalence of cholera. Its origin in the 
hot climate of Hindostan and its general progress 
prove this conclusively. In nearly all of the places 
where a great difference exists between the summer 
and the winter temperature the disease has disappeared 
during the cold season, and attained its greatest inten- 
sity during the hot months of the year. The only ap- 
parent exception to this rule is, that cholera has pre- 
vailed in several Russian, Swedish, and Norwegian 
cities during the winter. But these very exceptions 
confirm the rule; for in the countries mentioned the 
intense cold of the winter compels the inhabitants to 
seal their houses by every possible means, while the 
atmosphere within them is kept at a high temperature 
by huge stoves, which hinder ventilation, and indeed 
render it almost impossible. Difference of temperature 
likewise explains the fact that of two cholera-ships 
arriving from Havre, the one at New York and the 
other at New Orleans, in December, 1848, the former 
did not disseminate the disease, but the latter formed 
the starting-point of an epidemic which lasted all the 
winter. 

A good deal has been written of the predisposing 
causes of cholera, and poverty, crowding, filth, intem- 
perance, and depression of spirits have been given 

1 Peters's Notes, etc., 2d ed., p. 94. 



$6 CHOLERA. 

prominent places in the catalogue. But to any one 
familiar with the history of epidemic diseases it will at 
once be apparent that every one of these conditions 
favors the spread of all communicable infectious dis- 
eases. There is not the slightest evidence that these 
agencies, singly or combined, can generate cholera or 
favor its spread apart from the presence of the specific 
poison of the disease and the facility with which it is 
transmitted from the sick to the well whenever the 
population is crowded, poor, of filthy habits, and weak- 
ened by dissipation. Because among such people in- 
temperance prevails, this vice has been regarded as 
predisposing to cholera. Apart from the brutish mode 
of living of drunkards, there is nothing to show that 
they are more liable to cholera than the most abstemi- 
ous of water-drinkers. On the contrary, it is notorious 
that during cholera epidemics drunkards in the better 
classes of society enjoy a certain degree of immunity 
from the disease ; which it is easy to explain on the 
ground that they imbibe but little water, which is the 
main channel through which the infectious principle 
of the disease is spread. 

The specific cause of cholera is taken into the ali- 
mentary canal, and acts through it to produce the 
characteristic symptoms of the disease. It is conveyed 
from the sick to the well by means of the gastrointes- 
tinal discharges, either moist or dry ; in the former 
state, by means of drinking-water, and in the latter 
through the air, whose suspended noxious particles 
are received into the fauces and swallowed. There is 
reason to believe that the poison does not enter the 
system through the lungs, or through any other chan- 



. ETIOLOGY. 37 

nel than the gastro-intestinal canal. W. B. Carpenter 1 
appears to hold, however, that the poison may be ab- 
sorbed through the lungs. To this view there are two 
objections : I, That whatever is taken into the mouth 
or throat by inspiration may very well be swallowed ; 
and, 2, that all the primary lesions of cholera affect 
the digestive and not the respiratory apparatus. It is 
not at all necessary to the propagation of cholera that 
its excreta should be furnished by persons laboring 
under the fully-formed disease. A specific choleraic 
diarrhoea is as infectious as the evacuations which 
occur in completely developed cholera. But neither 
will propagate the disease through the air to a dis- 
tance. The tendency to its propagation in this manner 
depends chiefly upon the concentration of the poison ; 
thus, it much more frequently occurs in close than in 
well-ventilated rooms or than in the open air. It has 
been argued that cholera is not contagious, because so 
few, comparatively, of the attendants upon cholera 
patients contract the disease. On the other hand, as 
some of them are attacked, this positive fact outweighs 
an indefinite number of negative instances. It should 
also be noted that different diseases enter the system 
and infect it through different channels — some through 
the lungs, others through the alimentary canal, etc. 
Small-pox, the most contagious of all diseases, is in- 
troduced through the air-passages, and is probably 
harmless when its virus is taken into the stomach. 
That the converse of this proposition applies to cholera 
is sustained by the whole history of the disease. Chol- 
era-poison may be taken to considerable distances in 

1 The Nineteenth Century, Feb., 1884. 



38 CHOLERA. 

either a moist or a dry condition. In the former state 
it is mainly conveyed by water, as in rivers, water- 
pipes, etc. ; in the latter, by fomites, and especially by 
clothing saturated or merely soiled with cholera dis- 
charges, and which may retain their infectious quality 
for an indefinite time. 

Great stress has been laid upon the humidity and 
foulness of the soil, a damp atmosphere, filth, crowd- 
ing, etc., as elements in the production of cholera, but 
in reality they have no more essential relation to it 
than to any other disease that occurs epidemically. 
Cholera may prevail whether they are present or 
absent. It is evident that from the earliest historical 
periods all of these causes of disease have existed, and 
in Europe much more generally and excessively than 
during the present century, and that they have never 
been removed in Asia Minor, Egypt, Arabia, and 
Africa. Yet cholera never was known in any of these 
countries until it was brought into them about the end 
of the first third of the present century. 

According to Pettenkofter, cholera is most prevalent 
when the subsoil water is lowest, and least so when 
the subsoil water is highest. It would be more de- 
scriptive of the fact to say that, so far as cholera has 
anything to do with the condition of the soil, it is most 
apt to be severe and prevalent when very dry weather 
follows a very wet period. Such circumstances are 
the most favorable to putrefactive fermentation and the 
dissemination of its products, which thus reach wells 
of drinking-water, and even rivers, especially when 
sewers empty into the latter. The identity of this 
explanation with that which is generally accepted for 



ETIOLOGY. 39 

the dissemination of typhoid fever is too evident to be 
insisted upon. We might go farther, and say that, in 
typhoid fever as in cholera, the disease is communi- 
cated, although exceptionally, by the air of the sick 
room and by the exhalations of the soiled fomites of 
the patient. Now, if typhoid fever resembled cholera 
not only in being transmitted by means of the dejec- 
tions, but also in its poison being derived from one 
primary source only, the analogy between the causes 
of the two diseases would be very striking indeed. 
But, in point of fact, the typhoid-fever poison may 
probably be generated de novo by fecal fermentation 
and other forms of putrefaction, and the disease is only 
exceptionally communicable ; whereas, the poison of 
cholera, once received, is conveyed from man to man 
and far and wide through various channels ; but, so 
far as is known, it has but one primary source, and 
that is in India. Lebert states that he did not find the 
localities that are the ordinary seats of typhoid fever 
peculiarly liable to invasions of cholera. But it must 
be noted that typhoid fever is very far from being ex- 
clusively a disease of the poor, squalid, and vicious. 
Like death itself, " regum turres pauperumque tabernas 
aequo pede pulsat;" while cholera much more com- 
monly plants itself and disseminates its seeds in the 
rank soil of moral and physical degradation. 

All morbid causes whatever, derived from race, 
climate, religion, dwellings, food, clothing, habits of 
living, etc., have no more to do with the development 
of cholera than with that of the eruptive fevers, and 
even less than with the causation of typhus and ty- 
phoid fevers and dysentery. The eruptive fevers are 



40 CHOLERA. 

caused, as cholera probably is, by specific germs which 
no known combination of natural causes has ever de- 
veloped, while the poisons of the other diseases named 
appear to be generated anew whenever certain more or 
less definite physical conditions coexist. It would seem 
that cholera differs radically from all of these affections 
by the fact that its cause does not enter the circulation, 
but confines its direct operation to the gastro-intestinal 
mucous membrane. In this way it becomes intelligible 
that while, on the one hand, physicians and nurses of 
cholera patients, although often, in fact, yet in relation 
to their numbers, are comparatively seldom, affected, 
provided they duly observe proper sanitary rules, the 
disease, on the other hand, spreads like wildfire among 
those who drink water polluted by cholera excretions, 
and only a little less rapidly among people crowded 
into ill-ventilated apartments along with cholera pa- 
tients. 

The special fomites of the cholera-poison are arti- 
cles of clothing and furniture soiled with the dis- 
charges of the sick, and the emanations from privies, 
sewers, etc. into which these discharges have been 
cast. Many considerations render it probable that a 
very small quantity of cholera matter may suffice to 
render infectious a very large quantity of liquid, and 
especially of matters in process of putrefactive fermen- 
tation, and that the gaseous or vaporous emanations 
from them become diffused in the atmosphere and in- 
fect all who imbibe them. But water contaminated by 
cholera discharges is the most rapid and efficient agent 
in disseminating the disease. Innumerable instances 
of this mode of action are furnished by its history in 



ETIOLOGY. 41 

Asia and Africa, where water is often scarce, and natu- 
rally so impure that its additional defilement by 
cholera dejections is apt to pass unnoticed. From the 
illustrations of this proposition which might be ad- 
duced only a few of the more striking will here be 
selected. 

Hurdwar is a town in Northern India at the base of 
the Himalayas, where the Ganges begins its course in 
the plains. It is the seat of a great Hindoo pilgrim- 
age, which takes place annually in April, when some- 
times from 2,000,000 to 3,000,000 of people occupy 
an encampment of about twenty-two square miles, 
comprising a low flat island in the Ganges and the 
opposite banks of the river. Bathing in the sacred 
stream on a certain day is the main object of the 
devotees ; which day in the year 1 867 fell on the 1 2th 
of April. The bath was taken early in the morning. 
From noon on that day the pilgrims began to disperse 
so rapidly that on the morning of the 15 th the encamp- 
ment was quite deserted. It appears that up to the 
former date the health of the encampment was excel- 
lent, and it was the opinion of the reporter (Dr. Cun- 
ningham) that cholera was introduced into the camp 
by pilgrims from the neighboring districts going late 
to the fair. He believed that the cholera excreta may 
have been buried in the trenches and carried by a 
heavy rain into the river, and there swallowed by the 
pilgrims; for to drink of the water of the Ganges as 
well as to bathe in it is a religious obligation. 

Immediately after the breaking up of the camp cases 

occurred in the surrounding districts, the epidemic 

widening in all directions. The pilgrims were almost 
4* 



42 CHOLERA. 

always the first persons attacked in any locality, and 
the cholera attended them on their route wherever 
they went. In all the districts where the disease pre- 
vailed no cases occurred until ample time had been 
given for the pilgrims to reach them. In a word, " the 
cholera first showed itself among them ; it followed 
their lines of route only, and did not outrun them ; 
their progress was its progress, and their limits its 
limits." The mortality caused by this epidemic among 
the whole civil population of the North-western Prov- 
inces of the Punjab has been estimated at about 
1 1 7, 1 8 1. 1 The history of the religious festival of 1879 
was identical with that just sketched, except that the 
number of the pilgrims was smaller and the deaths 
proportionally less. 2 

Out of the numberless illustrations of the manner in 
which cholera is disseminated by water the following 
may be cited: In 1865 about 100,000 pilgrims were 
assembled at Mecca, of whom from 10,000 to 15,000 
fell victims to the disease, two-thirds of them within a 
period of six days. Some cause acting simultaneously 
upon the whole number of persons must be admitted 
to account for so extraordinary a fact, and such a 
cause is not far to seek. At a certain sacred well 
" one hundred thousand people had skinfuls of water 
poured over them at the side of the well, and every 
one of them then drank largely of water drawn from 
the well. Much of the water poured over the pilgrims 
must have found its way by soakage back into the 
well, and if any of the pilgrims were at the time suffering 

1 Brit, and For. Med.-Chir. Rev., Jan., 1870, p. 137. 

2 Murray, Practitioner, xxvi. 309. 



ETIOLOGY. 43 

from cholera, or had cholera-tainted garments about 
them, the well would be exposed to pollution." 1 

In the cholera epidemics of Zanzibar the disease 
produced the greatest havoc among the negroes, the 
Persians, and the East Indians ; very few Europeans 
were attacked, and quite as few of the sect of the 
Banyans, who drank only water drawn from their own 
wells. The persons among whom the disease pre- 
vailed so fatally used chiefly the water of a certain 
well which was highly prized, but which on this occa- 
sion had become polluted by soakage from an adjacent 
cesspool into which the dejections of cholera patients 
had been thrown. It appears, also, that in Zanzibar 
the streams are very rarely bridged, and hundreds of 
negroes, in passing backward and forward, wade 
through them and pollute them. In these streams, 
also, the negroes wash their clothes and all the foul 
clothing of the contiguous town. While this business 
is going on " a gang of negroes may be at work at not 
many hundred yards' distance filling water-casks for 
the shipping." Subsequently to the watering of the 
ships in this manner sailors were attacked with chol- 
era, and others who used water drawn from the stream 
below the place where it became polluted were at- 
tacked, and many of them died ; while Europeans living 
on shore, and who drank the water of the same stream, 
but drawn from a much higher point in its course and 
after having been filtered, escaped the disease. 2 

The history of the disease in Europe furnishes a 
multiplicity of similar cases, and even more distinctly 

1 Christie, Cholera Epidemics in East Africa, p. 488. 

2 Ibid., pp. 320, 492. 



44 CHOLERA. 

exhibits the dissemination of cholera by contaminated 
water. 1 In Holland not less than five epidemics of the 
disease occurred between 1832 and 1869, all of them 
causing a great mortality, to which the epidemic of 
1866 alone contributed not less than 20,000 deaths': 
This was about 55 deaths for every 10,000 inhabitants. 
Such exceptional mortality over so wide a territory 
has been ascribed to the extreme porosity and humid- 
ity of the soil, which is nearly all below the level of 
the sea. Such a soil must necessarily retain longer 
than other soils whatever it absorbs, and thus tend to 
render the well-water habitually impure, If. then, to 
the ordinary impurities a specific poison is added, its 
characteristic effects may assuredly be looked for. 
The conditions now stated explain the conclusions of 
Ballot of Rotterdam, drawn from a study of the several 
epidemics referred to. They are as follows : " I. Hol- 
land is highly affected by the cholera at every epi- 
demic, chiefly in those parts where they drink water 
directly from the rivers and canals or from ground 
saturated with sewage. 2. In places where rain-water 
is generally drunk the disease is far less violent. 3. 
Places where there is no other drinkable water but 
rain-water are not affected by the epidemic ; the single 
cases occurring there are imported. 4. When places 
affected by the cholera were supplied with pure water 
instead of the vitiated water the disease disappeared." 2 

1 It is of interest to note that on the first appearance of cholera in 
England, at Sunderland, in 1 83 1, a surgeon of that place, Mr. Ains- 
worth, collected and published conclusive proofs of the importation of 
the disease, of its communication from the sick to the well, " and of its 
propagation by clothes, and even by emanations, from the dead" [Ob- 
servations on the Pestilential Cholera, London, 1832). 

2 Med. Times and Gaz., May, 1869, p. 459; June, 1869, p. 626. 



ETIOLOGY. 45 

In like manner, we find that the cholera epidemic of 
1873 in Germany seemed specially to select those situ- 
ations where the subsoil was impregnated with decom- 
posing organic matter; and it is evident that, in cities 
especially, such situations would include the most 
poverty-stricken districts, while the higher, drier, and 
at all times more salubrious localities are inhabited by 
the classes enjoying the greatest material prosperity. 1 

Similar results of observation were obtained during 
the European epidemic of 1884. In a communication 
made to the French Academy by M. Proust he stated 
that the physicians charged with the study of epidemic 
diseases in several departments had made reports from 
which the following conclusions were to be drawn: I. 
Cholera was imported into the places where it pre- 
vailed ; 2. Water was an important agent in transmit- 
ting it ; 3. The severity of each epidemic was propor- 
tioned to the insalubrity of the place where it occurred ; 
4. The cessation of the epidemic in the affected places 
may be attributed in part to the hygienic measures and 
the disinfection employed. 2 

This mode of infection has been traced in number- 
less individual cases of cholera. In London there was 
a certain well into which the liquid contents of a sewer 
had been percolating for months. Of the water of this 
well hundreds of persons had been drinking without 
obvious injury. At last a case of cholera occurred 
hard by; the discharges were thrown into a privy 
which communicated with the sewer and indirectly 
with the well, whereupon more than 500 persons who 

lli Report of the German Imperial Commission," PracHtioner,xx.y'\. 153. 
2 Archives gen., March, 1885, p. 372. 



46 CHOLERA. 

drank water drawn from that particular well were at- 
tacked with cholera within three days. So in 1856 
cholera prevailed in the county jail of Oxford, Eng., 
the drain from which emptied into a pool from which 
the water was drawn to supply the city prison. In the 
latter institution cholera began to prevail, but declined 
as soon as the pipes conveying the water were cut off, 
and soon afterward ceased entirely. 1 Again, in Con- 
stantinople in 1865 the clothes, mattresses, etc. of 
cholera patients were washed at a fountain the basin 
of which was divided into two parts by a wall ; one 
part was used for washing clothes and the other for 
drinking purposes. Unfortunately, the waste-pipe of 
the former being obstructed, the foul water of one side 
communicated with the clean water of the other, and 
in one day 60 people died of cholera in the small por- 
tion of the city which was supplied from the infected 
source. The striking case has often been cited which 
occurred at Epping, Eng., where a woman brought the 
disease from a distance into a perfectly healthy house 
and neighborhood, and of ten persons affected with it 
seven died, including a physician in attendance upon 
one of them. An examination of the premises " dis- 
covered, below the pipes leading from the water-closet 
and from the eye-hole of the sink through which 
the choleraic dejections had been passed, a leakage 
which extended under the foundations of the building 
and entered the well. The sewage was distinctly trace- 
able on the side of the well corresponding with the 
leakage in the drain." After this discovery and the 
disuse of the foul water not another case occurred. 2 

x Edinb. Med. your., i. 1 122. 2 Trans, of the Epidemiological Soc, ii. 428. 



ETIOLOGY. 47 

In 1 868, Dr. Farr, in his History of the London Cholera 
Epidemic of 1866, showed that water into which chol- 
era dejections find their way produces cases of cholera 
all over the district in which it is distributed for a cer- 
tain period of time, and that if the distribution is in 
any way cut short the deaths from cholera begin to 
decline within about three days of the date at which 
the distribution is stopped. 1 Among the most recent 
examples which illustrate the diffusion of cholera by 
means of drinking-water is that presented by the epi- 
demic at Genoa in 1884. It was remarkable for not 
being confined to any one quarter or to the most insa- 
lubrious portions of the city. The verdict of experts 
appointed to investigate the subject was that the spread 
of the epidemic in all parts of the city was caused by 
impure water. It was understood, although not so 
officially reported, that out of 68 cases of cholera dur- 
ing the first three days after its appearance there were 
61 deaths, and that all of these victims had used the 
water brought from a certain aqueduct. It was also 
observed that fish died in fountains supplied by the 
water alluded to. 2 

Analogous instances are furnished by every cholera 
epidemic of which the history has been accurately ob- 
served, including that which extended so widely over 
the United States in 1873. Most of the following are 
cited from the official reports prepared, under the di- 
rection of the Surgeon-General of the army, by Sur- 
geon Ely McClellan and Dr. John C. Peters. Several 
of the first cases, however, are foreign. 

1 Lancet, April, 1868, p. 217. 

2 Medical Nexus, xlv. 474. 



48 CHOLERA. 

In 1 86 1, at a station in India, some fresh cholera 
dejecta found their way into a vessel of drinking- 
water. Early on the following morning a small quan- 
tity of this water was swallowed by nineteen persons, 
five of whom were attacked with cholera between the 
first and the third day afterward. 1 In 1876 an out- 
break of cholera took place in a village in Hindostan, 
which followed the arrival of wedding-guests, one of 
whom was attacked, and from whom it rapidly spread. 
The soiled clothes of one or more of the patients were 
washed in a pool from which all the villagers obtained 
their drinking-water, and on the discontinuance of this 
source of water-supply cholera speedily diminished in 
frequency and fatality. 2 In the German epidemic of 
1873 many cases occurred where persons deriving 
their drinking-water from special sources were at- 
tacked with cholera, while their neighbors, supplied 
from a different source, remained free. Again, it has 
frequently happened that outbreaks of cholera have 
been checked by the prohibition of the suspected 
water and the substitution of a pure supply. 3 It 
seems probable that a very small portion of cholera 
discharges suffices to infect a very large body of water 
and maintain its infectiousness for a considerable time. 

In December, 187 1, an outburst of cholera occurred 
which was confined to the inmates of three excellent 
houses in a fine block of buildings in Calcutta. There 
had been no cholera in that neighborhood for four 
years. Within forty-eight hours a majority of the 

1 Macnamara, op. cit., p. 196. 

2 Surg. -Major Cornish, Practitioner, xxiv. 215. 

3 Practitioner, xxvi. 159. 



ETIOLOGY. 49 

lodgers were sick, and on investigation it was found 
that the disease was carried in the drinking-water and 
in the milk diluted with it. 1 The particular locality 
in which Dr. Koch made the discovery of the micro- 
scopic representative of cholera furnishes an example 
of the same nature: "At Saheb Ragau, a locality which 
has repeatedly been visited by cholera during the last 
hundred years, numerous cases of the disease were 
reported, and these, on inquiry, were found exclusively 
in the huts situated round a certain tank. Of the few 
hundred people who dwelt in these huts, as many as 
seventeen died of cholera, though the disease was not 
at that time prevalent in the neighborhood, or indeed 
in the whole police district of Calcutta. It was proved 
that, as usual in such cases, the dwellers around the 
tank used it for bathing, and drew thence their drink- 
ing-water; it was also elicited that the linen of the 
first fatal case, befouled with cholera dejections, had 
been washed in the tank." 2 In June, 1873, a new hotel 
was opened at Vienna, and many of the guests became 
affected with diarrhoea that was attributed to the drink- 
ing-water, which was offensive to the taste and smell. 
After a fortnight a gentleman died of cholera in the 
hotel, and two days later several of the guests were 
attacked with the disease, of whom fourteen died. The 
gentleman who first died was believed to have brought 
the poison with him into the hotel, so that the drink- 
ing-water, which previously had been polluted with 
ordinary fecal discharges, became specifically affected 
through him. 3 The discharges of one ill of cholera 

1 U. S. Report, p. 85. 2 Times and Gas., April, 1884, p. 527. 

8 Ibid., p. 86. 
5 



50 CHOLERA. 

were thrown into, and the vessels used by him were 
washed near, a well from which all the residents of a 
farm-house drank. The wooden curbing of the well 
had rotted, and the ground immediately around had 
sunken ; a heavy rain burst the curb, overflowed the 
well, and washed into it the entire surface- drainage of 
the surrounding ground. No attention was paid to 
this, and the water was used as before. It became so 
offensive that its use was forbidden, but too late to 
save the family, nine of whom died of cholera. 1 

At Farmington, Tenn., a man arrived who had con- 
tracted the cholera at Nashville ; his illness ran its 
course at a point just forty paces from a well. Fam- 
ilies that obtained their water from this well suffered in 
nearly all their members ; where only certain members 
drank of it, they alone were affected. 2 At Huntsville, 
Ala., during an epidemic of cholera, the city author- 
ities forbade the use of well-water, and supplied pure 
water from another source, but only for one week. 
During this time no new cases of the disease occurred, 
and the negroes, thinking themselves secure, resumed 
the use of the well-water, and within four days six 
fatal cases of cholera occurred in the vicinity. The 
use of the well-water was again prohibited, and again 
the progress of the disease was arrested. 3 

It has already been intimated that the cholera-poison 
may be diffused through the air from either moist or 
dry sources, and especially from contaminated clothing, 
and then be taken into the throat and swallowed. Dr. 

1 Times and Gaz., April, 1884, p. 140. 2 Ibid., p. 172. 

3 Ibid., p. 408. For other examples of the spread of cholera by 
means of drinking-water see Macnamara, p. 149 and seq. 



ETIOLOGY. 51 

Richardson refers to a local epidemic in England in 
which " the persons most constantly and fatally at- 
tacked were the women who washed the clothes of the 
sick ;" and this circumstance has been largely confirmed 
by other observers. 1 During the Crimean War many 
of the washermen attending to the washing of the 
French hospitals were attacked by cholera. Dr. 
Koch, in his Report on the Cholera in Egypt, speaks of 
the frequent infection of washerwomen who had to 
wash soiled linen, and he refers to a case of the kind 
which occurred, during the existing epidemic, in the 
Greek Hospital in Alexandria. 2 In the post-office at 
Marseilles none of the clerks who handled the out- 
going mails were attacked, but of those who sorted the 
mails coming from the East, where the disease pre- 
vailed, one after another suffered from cholera. 3 

The cholera was introduced into Guadaloupe by 
clothing contained in a trunk belonging to a person 
who died on the voyage thither from Marseilles, where 
the cholera then prevailed. The woman who washed 
the clothing died, with all her family. Attracted by 
the circumstances of the case, many came to her house, 
and of these several died. From this point the disease 
spread over the island. 4 A sailor died at some port in 
Europe of Asiatic cholera in 1832. A chest contain- 
ing his personal effects, clothing, etc. was sent home 
to his family, who lived in a small straggling village on 
the Atlantic coast of the State of Maine. It reached 
them about Christmas, and was opened on its arrival. 

1 Trans. Epidem. Soc, ii. 429. 

2 Times and Gaz., October, 1883, p. 448. 

' Read, Boston, 1866. * Med. Times and Gaz., April, 1 874, p. 387. 



52 CHOLERA. 

The inmates of the house were all immediately and 
suddenly seized with a disease resembling Asiatic 
cholera in all its malignity, and died. There had been 
no cholera in the State. The last case of cholera that 
occurred in the garrison at Malta in the epidemic of 
1865 was that of a woman who had stolen a chemise 
the property of one who had died of the disease. She 
put on this fatal garment, probably soiled with cholera 
discharges, and certainly unwashed, many days after 
the death of its former possessor; she took the dis- 
ease and died. 1 

In 1884 a limited, but severe, outbreak of cholera 
took place at Yport, a Norman fishing-village. On the 
7th of September a fishing-vessel from Newfoundland 
arrived at Cette, in the south of France, where cholera 
prevailed, and several of the crew were attacked by 
the disease and two died. Two of the men reached 
Yport on September 28th. One of them had suffered 
a choleraic attack at Cette, and the day after his arrival 
his clothes were, with the aid of his brother and his sis- 
ter-in-law, wrung out in water and hung up in front of 
the neighboring dwellings, the slop- water being allowed 
to flow down the street. On the 4th of October the 
sister-in-law, then suffering from diarrhoea, washed out 
these same garments at the foutaine, and was seized 
with all the symptoms of Asiatic cholera and soon 
died. Another woman died on October 8th, and five 
others before the 22d. The total attacks were 42, of 
which 15 were fatal. 2 

It is sometimes said, and oftentimss repeated, that 

1 Lancet, Feb, 17, 1 866. 

2 Practitioner, xxxiv. 157- 



ETIOLOGY. 53 

cholera is not directly contagious — is not communi- 
cated by the sick to the well. No statement could be 
more unfounded. The whole history of cholera proves 
that the physicians and nurses of cholera patients are 
often affected by the disease. " In Constantinople no 
less than twenty-seven physicians and medical assist- 
ants were attacked and died during their attendance 
on cholera patients ; and in Paris and Toulon similar 
results followed. At Halifax, N. S., two of the phy- 
sicians who volunteered in aid of the steamer England, 
which put in there disabled by the ravages of cholera 
among the officers and crew, as well as among the 
steerage passengers, took the disease, and one died " 
(Read). In 1832 the cases of cholera in Edinburgh 
were in the proportion of 1 to every 1200 of the pop- 
ulation of the city, while among those in attendance 
upon the sick the proportion was I to 5. In 1848-49 
one-fourth of the nurses employed in the cholera hos- 
pital took the disease, while in the general hospital, 
only a few paces distant, where no cholera patients 
were received, not a single attendant was attacked. In 
the London Hospital, in 1866, none of the medical 
officers, volunteer nurses, or sisters were attacked, 
Of the (regular) nurses five contracted the disease, and 
of these four died. 1 In 1849 a severe and fatal epidemic 
broke out in the Philadelphia Almshouse. The resident 
physicians of the hospital were abundantly occupied 
with the care of the sick of other diseases, and it was 
thought prudent not to allow any, even an indirect, 
communication between them and the cholera patients. 
The latter were therefore removed to an isolated build- 

1 London Hosp. Rep., iii. 439. 
5* 



54 CHOLERA. 

ing in the middle of the quadrangle, and attended by 
physicians from the city who had volunteered their aid. 
Three or four of these physicians had attacks of cholera, 
and two of them died. 1 At this time there was no 
cholera at all in the city, and the young physicians 
could not have become infected outside of the alms- 
house. They were attacked while attending the sick 
of cholera, but the regular house-physicians, who sel- 
dom visited the cholera patients, escaped altogether. 

Again, some physicians claim that cholera is not 
contagious because it is not conveyed by contact or by 
inoculation, but as typhoid fever and dysentery are 
transmitted. 2 Then typhus and typhoid fever, and 
perhaps scarlatina and measles, are not contagious ! 
This writer admits that cholera is " infectious " through 
air or water, or in the same manner as dysentery ; in 
other words, it is communicable by the sick to the well. 
This is an essential and unquestionable fact in the his- 
tory of the disease ; let those who prefer to describe it 
by one term rather than another please themselves in 
their choice. 

The importance of recognizing the communicability 
of cholera is so great that no apology need be made 
for introducing the following additional illustrations of 
it furnished by Griesinger in his article on the dangers 
of cholera to medical men. They are the more import- 
ant because in many other instances cholera physicians 
have suffered little for their devotion to duty : " At 
Moscow, in 1840, hospital attendants contracted the 
disease to the extent of 30 or 40 per cent., while in the 

1 Philada. Med. Examiner, Nov., 1 849. 

2 Dutrieux Bey, Le Cholera dans la basse Egypt, en 1883. 



ETIOLOGY. 55 

general population only 3 per cent were attacked ; at 
Berlin, in 183 1, in Romberg's hospital, 54 out of 115 
persons were attacked: in 1837 one-fifth of the attend- 
ants took the disease, and on one occasion no less than 
seven of them fell ill on a single day. In La Charite 
Hospital in Paris, in 1849, one-sixth of the attendants 
had the disease, while only one-twenty- fifth of the 
general population of the city suffered from it; at 
Mittau, in 1848, one-half of the physicians took the 
disease; in 1842, at Toulon, ten health officers out of 
thirty-five were ill with cholera, and five of them died, 
while of thirty workmen who were employed to carry 
the dead bodies one-third succumbed ; at Stockholm, 
in 1853, of 536 attendants one-eighth took the disease, 
and half of that number died; at Vienna, in 1854, out 
of thirty-six nurses, seven caught the disease, and seven 
men employed in removing the dead became affected 
with a prolonged and exhausting diarrhoea; in 1849, 
at Strasburg, five nurses out often were attacked, etc." 
. . . . " Physicians, nurses, students, etc. are less fre- 
quently affected, however, than patients ill with other 
diseases who are lying in the wards where cholera pa- 
tients are treated, and who are therefore more constantly 
exposed to the emanations from the discharges ; and 
physicians usually suffer less than the attendants who 
are constantly waiting on the cholera patients." 1 

It may be added that Surgeon-General John Murray, 
who served continuously for thirty-eight years in Brit- 
ish India, caused upward of five hundred circulars to 
be addressed to the local governments and filled up by 
the local medical officers. From these, returns it ap- 

1 Traite des Maladies infectieuses, 1868, p. 409. 



56 CHOLERA. 

peared that the belief in the communicability of chol- 
era, in one way or another, was practically unanimous ; 
for of the whole number, those who believed that it is 
conveyed from person to person were 75 per cent. ; 
from place to place, 85 per cent; through the atmo- 
sphere, 80 per cent. ; with the drinking-water, 85 per 
cent. ; by the evacuations, 92 per cent. ; and by cloth- 
ing, 98 per cent. 1 This gentleman has more recently 
furnished additional facts supporting the same conclu- 
sion. For example: Out of fourteen cases that occurred 
at Ramleh during the Egyptian epidemic, eleven oc- 
curred in patients already in the hospital for other 
diseases. In 1856, after visiting the dead-house where 
the bodies of fourteen cholera patients lay, as he 
entered the cholera ward he felt a sudden shock in 
the epigastrium, followed by a deadening sensation 
that rapidly spread over the whole body. On another 
occasion he saw a clergyman who was talking to a 
cholera patient suddenly seized with vomiting of a 
watery liquid. Several analogous instances are related 
by him. 2 

It has been objected to the communicability of 
cholera that its dissemination does not always follow 
the deposit of cholera discharges in privies, wells, etc., 
and also that when infection does take place, it may 
occur between remote extremes as to time, and there- 
fore cannot be attributed to infectious germs. Such 
objections are frivolous, because we know nothing of 
the nature or vitality of cholera-germs, and they are, 
moreover, drawn from exceptional cases. The power 

1 Practitioner, xix. 470. 

2 Med. Times and Gaz., March, 1884, p. 281. 



ETIOLOGY, $7 

of infected fomites to develop the disease has been 
preserved, in a journey from Arabia into Africa, for 
at least twelve days, and for even a longer period in 
passing from Germany to Chicago, as already related. 
It is true of every infectious and contagious disease 
that it may possess one or both of these qualities in 
various degrees — that at one time it is only exception- 
ally communicated, and that at another time it appears 
to propagate itself virulently. So the phenomena of 
cholera may consist of little more than a watery di- 
arrhoea, which may be so mild as hardly to disable 
the patient from working, while at other times the 
attack may include all those terrible and fatal symp- 
toms which have won for the disease the name of 
malignant. That a certain quantity, or " dose," of the 
cholera-poison is required to develop the disease, but 
one that varies considerably in different cases, may be 
inferred from these facts: I. Out of a certain number 
of persons equally exposed to receive the disease, only 
a portion may be attacked at all, and these in very 
unequal degrees. 2. Persons so slightly affected as to 
be ignorant of the nature of their sickness, and believ- 
ing it to be an ordinary diarrhoea, may nevertheless 
become the innocent, because ignorant, disseminators 
of cholera. The explanation of such facts may be 
manifold : they may depend upon the dose or upon 
the energy of the morbid poison, on various possible 
conditions of its recipient, and so on ; but, however 
explained, their reality is none the less certain. The 
receptivity of persons exposed to the contagion of 
cholera is very different. It is well known that some 
persons appear to be proof against other contagious 



58 CHOLERA. 

diseases, while others seem never to acquire an immu- 
nity from them. On this very important point the 
conclusions of Fauvel directly bear. 1 They include 
the following propositions : The East Indian ports 
where cholera exists as an endemic disease are never 
the seat of an extensive epidemic among the native 
population. But strangers to these localities are liable 
to the disease, and such are the Mussulman pilgrims 
who come to Bombay to take ship for Mecca. A 
severe epidemic of cholera confers upon the locality 
in which it has taken place an immunity which in 
India appears to be of several years' duration. Such 
an epidemic in any country is a proof that the cholera 
is not endemic there. 

If a contagious disease preserved its virulence undi- 
minished, it might continue to prevail indefinitely. 
But we know that all other contagious epidemics do 
come to an end sooner or latter, and hence we must 
conclude that their specific cause progressively loses 
its virulent qualities. There is every reason, therefore, 
to believe that the same is true of cholera. Its com- 
municability, and therefore its diffusion, may vary with 
climatic, seasonal, local, personal, and other conditions; 
but of what nature those conditions are, and especially 
of the last and most important, the personal, hardly 
anything is known. Nor need we too curiously inves- 
tigate them, so long as the fact remains that outside 
of, and independent of them all, there is but one essen- 
tial cause of cholera — a morbid poison as specific in 
its nature as that of any of the eruptive fevers — a 
poison which no determinable conjunction of circum- 

1 Me moire lu a V Acadhnie des Sciences, 1883. 



ETIOLOGY. 59 

stances has ever engendered, and which was unknown 
in Europe and America before it was carried to them 
from India. In just such a way did small-pox first 
arise in the Western World. It had never appeared 
in Europe until the latter part of the sixth century, 
when for a short time it prevailed in Marseilles and 
the neighboring country. Afterward it was not heard 
of until it was reintroduced by the Crusaders on their 
return from Palestine in the twelfth century, since 
which period it has hardly ever ceased. The history 
of the diffusion of cholera is closely analogous to this 
in several particulars, and we may reasonably expect 
that what was in the last generation a new disease will 
henceforth be liable to prevail again and again as the 
intercourse increases between the nations of the West 
and the immemorial source of cholera in Hindostan. 1 
In the preceding discussion of the origin and dis- 
semination of cholera the broad facts of its specific 
nature and its contagion by means of excreta have 
been chiefly insisted upon. Little has been said either 
of the nature of the contagium or of the conditions 
that modify its activity. These points will be consid- 
ered hereafter. But it is proper in this place to state 
that, in the opinion of most investigators, the contagi- 
ous element has the power of multiplying itself, not 
only within the body, but wherever it is in contact 
with decomposing organic matter, provided that the 
degree of heat and amount of moisture present are 
adapted to promote such a change, which is certainly 
analogous to fermentation, if not identical with it. And 

1 Additional illustrations of the communicability of cholera are con- 
tained in the Brit, and For. Med. Chir. Rev., July, 1872, p. 56. 



60 CHOLERA. 

the facts already mentioned may be recalled, which 
show that the contagium cannot be a light and subtle 
substance, since, as has been stated, the immediate at- 
tendants upon cholera patients are not as apt as might 
be expected, on that hypothesis, to contract the dis- 
ease, while washerwomen inhaling, and probably swal- 
lowing, the moist fumes from cholera fomites much 
more frequently do so ; that fomites saturated with the 
dried discharges are very infectious ; and that water is 
the principal vehicle by which cholera-germs are car- 
ried into the stomach. 



SYMPTOMATOLOGY. 

Like other diseases, cholera occurs under very dis- 
similar aspects and with various degrees of gravity. 
Like those especially which are caused by specific 
morbid poisons, it may be so insignificant as to escape 
recognition, or, on the other hand, it may give rise to 
violent and distressing symptoms which come on with- 
out warning and hurry the patient to inevitable death. 
Whenever epidemic diseases present such opposite ex- 
tremes of severity in their symptoms, it may reason- 
ably be inferred that the differences depend mainly 
upon the quantity of the poison that has been received 
into the system, precisely as the dose which has been 
taken of a narcotic or acrid poison may be estimated 
by the gravity of its effects. Individual peculiarities, 
constitutional or acquired, may modify the characteris- 
tic phenomena, and sometimes a careful inquiry may 
be necessary even to detect their existence ; but a 



S YMP TO MA TOLOGY. 6 1 

study of cholera in all its grades shows that its symp- 
toms are all the effects of one and the same cause, and 
that the cholera-poison acts primarily upon the gastro- 
intestinal mucous membrane. It follows, as a matter 
of course, that, being thus applied, it will occasion 
symptoms differing in degree and in kind according 
to the energy of its action, and that this, again, will 
depend partly upon the inherent virulence of the agent 
and partly upon its quantity. In fact, this feature in 
the clinical history of the disease can be explained 
only by the operation of a special irritant acting with 
different degrees of power upon the gastro-intestinal 
mucous membrane. In other words, the different 
forms under which it is convenient clinically to recog- 
nize and describe cholera are nothing more than differ- 
ent degrees of the operation of one and the same poison 
modified more or less by the peculiarities of individual 
patients. In the most typical of the fully-formed cases 
of cholera there is a stage of diarrhoea, a stage of 
cholera morbus — i. e. of vomiting and purging — with 
more or less evidence of stagnation of the blood, which 
is followed either by reaction and recovery or collapse 
and death: The phenomena of those several stages 
will now be described, after which certain symptoms 
will be more particularly considered. 

It has more than once been pointed out that, how- 
ever mild an attack of cholera may be, the dejections 
accompanying it are infectious, and may produce in 
other persons the gravest types of the disease. Hence 
the importance, not only to the patients, but also to 
others, of recognizing it in the earliest stage ; for while 
this knowledge may suggest measures for preventing 



62 CHOLERA. 

an extension of the d'sease, it leads to the prompt use 
of remedies at the only period in which their success 
can at all be counted upon. The characteristic of this 
stage, which has generally been called either choleraic 
diarrhoea or cholerine, is a diarrhoea remarkable for its 
profuseness and the frequency and serous quality of the 
stools, which are, however, of a more or less yellow 
color. They are preceded by rumbling and gurgling 
noises in the abdomen, are voided without colic or 
tenesmus, and are followed by a remarkable sense of 
exhaustion or faintness, which is sometimes also ac- 
companied with nausea, and if they are very frequent 
and copious, cramps are apt to be felt in the calves of 
the legs. In this variety or stage of the attack, as a 
rule, there is not any vomiting ; there is complete an- 
orexia, but urgent thirst, a white and clammy tongue, 
and a peculiar alteration of tone, a huskiness, faintness, 
or hoarseness of the voice. The stools vary from six 
to twelve a day, and, as above stated, are slightly yel- 
low ; they are also alkaline, and on standing deposit a 
granular sediment which consists largely of the debris 
of intestinal epithelium. Unless the attack is very 
severe the temperature is not lowered by much more 
than i° F. The symptoms now described, especially 
in their milder grades, may last for a week or even 
longer, and then, according to circumstances, end either 
in cure or in fully-developed cholera ; but under appro- 
priate treatment they usually subside in a day or two, 
and more or less rapidly according to the degree of 
damage done to the digestive mucous membrane. 

Between the above, which is the mildest type of 
epidemic cholera, and the fully-developed disease must 



S YMPTOMA TOL OGY. 63 

be placed that grade of the disease which is more ap- 
propriately called cholerine, comprising cases in which 
vomiting occurs as well as purging, with increased de- 
bility and a tendency, more or less decided, to collapse. 
The matters vomited, after the rejection of undigested 
food, are at first bilious, but they gradually become less 
and less so the longer the attack lasts, and, together 
with the stools, assume the appearance of rice-water — 
i. e. they consist of a pale grayish, semi-transparent 
liquid in which white flocculi are suspended. Its re- 
action is alkaline, and it has a faint albuminous or sper- 
matic smell. Along with these symptoms the other 
effects of serous depletion arise — debility with pallor, 
duskiness, coldness, profuse perspiration, and a sodden 
condition of the skin, while the secretion of urine is 
diminished, and all the symptoms that belong to the 
first stage of cholera are present in an aggravated de- 
gree. 

A curious feature of this disease is that sometimes 
the onset even of its graver forms is not attended by 
any evacuations, although the stomach and intestine 
may be filled with liquid. It is perhaps chiefly in 
such cases that the patient experiences a rapid depres- 
sion of all the mental and physical faculties. The 
senses are irritable, the head aches and is confused, 
there is a disinclination to sleep, the limbs totter under 
the weight of the body, the pulse is frequent and feeble, 
occasionally fainting takes place ; the skin is cool and 
bedewed with perspiration. In other cases, again, the 
attack is sudden ; the patient is smitten with an unac- 
countable feebleness, speedily followed by profuse vom- 
iting and purging and general spasms, and dies with- 



64 CHOLERA. 

out any suspension of the symptoms or any tendency 
to reaction. 

But more usually the attack begins with the diar- 
rhoea and vomiting described above, which then as- 
sume, more or less rapidly, a high degree of violence, 
expressed by their frequency and excess. The stools 
with proportionate rapidity lose all their fecal qualities 
and acquire the rice-water appearance before mentioned, 
and the liquid rejected by vomiting in all respects re- 
sembles them. It is poured forth less by an ordinary 
act of vomiting than by gushes, as if it overflowed 
from the throat and mouth ; and it often escapes from 
the stomach and the bowels at the same instant. Such 
profuse evacuations necessarily occasion an urgent 
thirst which cannot be satisfied, for liquids are thrown 
up immediately on being swallowed. Sometimes a 
distressing hiccough accompanies these symptoms. 
It is indeed only one of the many spasms which may 
affect the muscular system. They generally begin in 
the fingers and toes, which become bent and stiff; 
they seize upon the muscles of the calves of the legs, 
and render the muscular wall of the abdomen as hard 
as a board. The pain they produce is extremely se- 
vere, and unless the patient is exceedingly prostrated 
he endeavors to assuage it by a constant change of 
position. 

At this period the debility is very great, and pro- 
gressively increases, and the patient is unable to rise, 
or even to move at all except under the stimulus of 
the painful spasms. The features are shrunken ; the 
nose is sharp and pallid, and bent to one side ; the 
dusky, lack-lustre, and sunken eyes, the thin lips, the 



S YMP TO MA TOL OGY. 6$ 

hollow cheeks, and the contracted muscles that stand 
out like cords under the tense and clammy skin, pre- 
sent a physiognomy that belongs to no other disease 
in the same degree. The hands and feet grow cold, 
and steadily the coldness creeps upward toward the 
trunk; the temperature falls to 94 or 95 ° F. ; the 
feeble and even flickering pulse ranges from 100 to 
120. The integuments of the limbs are shrivelled and 
damp, and look as if they had been macerated in 
water ; and if a fold of the skin is pinched up, it sub- 
sides very slowly indeed. The eyes grow dull and 
dry, the tongue has a pasty or sticky feel, and the 
urine is almost suppressed. If any of this excretion 
can be obtained for examination, it is found to contain 
both albumen and sugar. As the attack advances the 
patient falls into a dull, listless, and motionless state, 
which may be mistaken for insensibility or even un- 
consciousness, but is really due to exhaustion of all 
the faculties of mind and body. He may express no 
interest in anything, and hardly notice the attention 
or the distress of his friends, yet he will generally 
give clear, although languid, answers to questions, 
and fall again into an inert and unobservant state. 

As these symptoms continue and the fluids of the 
body decrease, the blood accumulates and stagnates 
in the veins, giving to the hands and feet, the nose and 
lips and other features, to the neck, and even to the 
entire surface of the body, a bluish, leaden, or violet 
tint, precisely like that of cyanotic children. The 
pulse, that was already weak and thready, is no longer 
perceptible ; the carotids even and the impulse of the 
heart cease to be felt, and the second sound of the 



66 CHOLERA. 

latter becomes inaudible. The skin is everywhere 
cold ; the hands, feet, and face are sometimes of an 
icy coldness, and yet the patients seldom perceive that 
they are so ; indeed, complaint is more apt to be made 
of suffering from internal heat. Even the breath as it 
issues from the nostrils feels cold. The blood no long- 
er circulates, and the heart seems still. If a vein is 
opened a few drops of black and viscid blood will 
trickle from the wound, which if it coagulates, yields 
but little serum, and in place of a firm clot only a dif- 
fluent jelly. The voice has sunk to a mere whisper 
or is quite extinct. The features assume a distorted 
and frightful expression ; the temples and cheeks are 
hollowed ; the nose is twisted and pointed, and the 
nostrils are obstructed with dry and powdery crusts ; 
the eyes are also dry, dull, and sunken behind the 
half-closed and purple lids ; the conjunctiva is no 
longer moistened by its secretion and becomes blood- 
shot ; the temperature in the mouth may fall to 79 or 
8o° F. ; a viscid exhalation bedews the icy and mar- 
bled skin ; and the whole body is so shrunken from its 
natural proportions as to lose all the marks by which 
its identity has been recognized. From this pulseless, 
exhausted, cold, and cyanotic condition there can be 
but one step to death. It generally comes on grad- 
ually, the patient sinking into the state of apparent 
insensibility before mentioned ; on the other hand, he 
may expire suddenly on attempting to make some un- 
usual effort. 

At any period in the progress of cholera, except that 
of complete asphyxia, the contest between the system 
and the disease may be decided in favor of the former. 



S YMPTOMA TOL OGY. 6j 

If this occurs before profuse evacuations have taken 
place or blueness of the skin appeared, the recovery 
may be gradual and present no special phenomena. 
The pulse regains by degrees its natural force ; the 
skin grows warm again, first upon the trunk and after- 
ward upon the extremities ; the breathing becomes 
easy, and, the diarrhoea having already ceased, con- 
valescence is established. But in proportion to the 
severity of the symptoms, the intensity and duration 
of the cold stage, the cramps, and the evacuations, will 
there be a tendency to febrile reaction, with more or 
less passive congestion of the internal organs, and 
therefore a slower return to health. If the attack has 
been very severe, and particularly if the algid stage 
has been prolonged, fever of a low type is apt to occur, 
and indeed may terminate fatally. This fever presents 
all the characters of the typhoid state, and is marked 
by dryness of the tongue, a brown crust upon the 
teeth and gums, jerking of the tendons, delirium, and 
coma. These symptoms are partly evidences of ex- 
haustion, of inability of the system to resume its nor- 
mal action, and perhaps also they denote the retention 
of the effete products of nutrition in the blood ; but 
sometimes they appear to be associated with, and 
caused by, a local and latent inflammation of low 
grade, established usually in the lungs. Again, the 
nervous system seems to bear the brunt of the reac- 
tionary effort, and the patient is attacked by convul- 
sions or perishes in an apoplectic fit. These phe- 
nomena appear to be due in most instances, if not in 
all, to renal obstruction, and, as it is supposed that 
their immediate cause is the retention of urea in the 



68 CHOLERA. 

blood, they have received the title of uraemic. In 
other cases a wasting diarrhoea, due probably to the 
damaged state of the intestinal mucous membrane, is 
superadded to the already existing typhoid state. Oc- 
casionally the parotid glands become enlarged and 
painful, and sometimes a measly or roseolous eruption 
appears upon the skin. 

It frequently happens that the convalescence from 
cholera is slow and irregular. The system seems to 
be shattered by the trial it has passed through ; the 
nervous susceptibility is for a long time morbidly in- 
creased, or, what is still more usual, the digestive func- 
tion is greatly impaired. The appetite is capricious 
and the digestion feeble. The mouth is pasty, the ab- 
domen tympanitic, the bowels are irregular and alter- 
nately confined and relaxed. Finally, patients who 
leave the bed too soon or indulge prematurely in their 
ordinary diet are liable to a relapse, perhaps fatally, 
into the original disease. It has sometimes happened 
that such a relapse has taken place several days after 
an apparent restoration to perfect health. 



COMPLICATIONS AND SEQUELS. 

In a small proportion of cases, as above stated, cuta- 
neous eruptions have been observed during the attack 
of cholera, or rather during its decline, for they coin- 
cide with the reaction or follow it, and may be regard- 
ed as indications of increasing vitality. They belong 
to the exanthematous class, and comprise roseola, ery- 



COMPLICATIONS AND SEQUELAE. 69 

thema, urticaria, and rarely vesicular eruptions. 1 But, 
instead of them, there may occur destructive tissue- 
lesions in the form of abscesses or ulcers. These af- 
fections are more usual on the limbs than on the trunk 
or face, but some of them may appear even in the 
mouth or fauces. Profuse sweats have been noticed 
elsewhere, and the important fact that they carry off 
large quantities of urea, which they deposit upon the 
skin. Diphtherial exudation has also been met with 
upon tender parts of the skin and in the fauces, as well 
as in the stomach and intestine. In some epidemics 
of cholera suppuration of the parotid gland is occasion- 
ally observed, while in others it may be entirely ab- 
sent. Instances have been reported of double parotitis, 
and in several of them the termination of the attack 
was fatal. Still more rarely suppuration of the sub- 
maxillary or the cervical glands has been met with. 
Another sequela of cholera is a tetanic contraction of 
the flexor muscles of the limbs. Between the tenth 
and fifteenth days of convalescence the patient is at- 
tacked with a tearing, rending pain in the hands and 
forearms, the legs and feet, followed by tonic contrac- 
tion of the flexor muscles of these parts. The sen- 
sibility is not impaired. The attack lasts for one or 
several days, and seems always to end in recovery 
(Guterbock). 

Some of the individual symptoms of cholera call for 
a more detailed notice than they have received in the 
foregoing epitome, in which the continuity of the nar- 
rative could not be interrupted by a description of 

1 Compare London Hosp. Reports, iii. 457. 



JO CHOLERA. 

variations depending upon the stage and grade of the 
disease. 

The first to be considered is the temperature. The 
animal temperature in cholera varies according to the 
part of the body at which it is taken more than in any 
other disease. In cases of average severity it rarely 
falls below 95 ° F. in the axilla. The temperature un- 
der the tongue does not furnish trustworthy indica- 
tions. In the stage of asphyxia it seldom exceeds 
87. 8° F., and even in cases that recover it may fall to 
about 78. 8° F. (Wunderlich). In the cold stage it is 
not uncommon for a difference of temperature to be 
noted of nearly ten degrees between the axilla and the 
rectum. In a female aged thirty-two the temperature 
in the axilla was 93 F., and that in the vagina 102. 8° 
F. (Mackenzie). In other cases a vaginal temperature 
of 104 F., and even of 108. 32 F., has been reached 
(Guterbock). Such high temperatures furnish an un- 
favorable prognosis. As Wunderlich has pointed out, 
during the algid stage temperatures taken in the 
mouth do not give an accurate idea of the general 
temperature ; the rectal and vaginal temperatures are 
more nearly correct. The following are some results 
of thermometry in 74 cases of cholera : Lorain found 
the minimum rectal temperature in I case 93. 2° F., in 
2 cases 95 , and in 10 cases 96.8 . In 47 cases the 
normal temperature was preserved ; in 27 it rose to 
100.4 ; in 15 cases to 102. 2° ; and in 1 to 104 F. 
Leubuscher gives the average temperature in the 
armpit 92. 7 F. ; under the tongue, 90.5 °;. upon the 
tongue, 8 1. 5 , in the nostrils, 79.2 ; and on the palm 
of the hand, 84 F. These numbers, however, only 



COMPLICATIONS AND SEQUELS. J I 

represent averages. It should be noted that the low 
temperature of the mouth and nostrils is caused not 
only by the evaporation from the surface of those cavi- 
ties, but also by the relative coldness of the expired 
air, due to the partial suspension of the passage of 
blood through the lungs, and therefore to the heating 
of the air contained in them. According to Leu- 
buscher also, the lowest temperature is found in the 
nostrils, and next under the tongue, and at the latter 
point it may vary from 79 F. to 90. 5 ° F. In death 
by asphyxia the vaginal and rectal temperatures may 
rise to i04°-io8° F. The axillary fluctuates less than 
the internal temperature. It is remarkable that during 
the algid stage the patients, at least before the tempera- 
ture has reached its minimum, are not conscious of 
their coldness, but, on the contrary, complain of inter- 
nal heat, precisely as happens in the congestive forms 
of periodical fever. When the febrile reaction assumes 
a typhoid type the temperature in many cases is nor- 
mal or only slightly elevated, and it is of serious im- 
port if the temperature then sinks again below the 
normal grade (Wunderlich). On the whole, the main- 
tenance of a uniform temperature, neither much above 
or below 90 F. in the axilla or under the tongue, may 
be regarded as favorable, yet recoveries have taken 
place even when the temperature at these points has 
fallen to 79 F. If the temperature of the parts just 
mentioned should rise rapidly to 104 F., it may be 
regarded as a very unfavorable sign. 

The skin, as has elsewhere been described, is pallid, 
bluish, shrunken, and cold, and quite destitute of its 
natural firmness and elasticity, so that when it is 



72 CHOLERA. 

pinched into folds they subside very slowly, as if they 
had been made on the skin of a corpse. It is curious 
that, although the drain of liquids through the bowels 
is so great, the skin not only remains moist, but gener- 
ally is bathed in a profuse cold sweat. Although the 
secretion of urine is reduced or quite suspended, that 
of milk is said to be not always so. Large quantities 
of urea have been found in the urine, and in some cases 
it has been visible upon the skin in the form of white 
scales. During convalescence the skin may be the 
seat of the various eruptions already enumerated. Of 
a graver nature, but, fortunately, of rarer occurrence, 
are erysipelas, boils, abscesses, ulcers, and gangrene. 
These several affections seem to result from the alter- 
nate obstruction and freedom of the cutaneous circula- 
tion. They commonly appear first upon the limbs, 
and afterward upon the face or trunk; they may affect 
even the cavity of the mouth. Some observers have 
noted a relatively frequent occurrence of diphtherial 
exudations in this disease, while others do not allude 
to their existence. The former describe the false 
membrane as affecting not only the mouth and fauces, 
but also the stomach, the intestine, and the female or- 
gans of generation. A case is reported by Joseph of 
a young man who, after an attack of cholera, was af- 
fected with a blenorrhcea, due to a diphtherial inflam- 
mation of the urethra. 

The character of the heart- and pulse-beats in this 
disease is quite peculiar. Their rate does not increase 
indefinitely, as it does after hemorrhage ; the pulse 
usually varies from 90 to no, and indeed seldom 
exceeds 120, but its volume, tension, and force pro- 



COMPLICATIONS AND SEQUELS. 73 

gressively decline until the beats become imperceptible 
at the wrist, and even in the brachial and femoral 
arteries. At the same time, the rhythm of the heart 
is interrupted, the energy of its impulse declines until 
it can no longer be felt, and its sounds grow weaker 
and weaker until they become quite inaudible. Some- 
times, it is said, a pericardial friction sound may be 
heard, which is attributed to the dryness of the peri- 
cardium. That the decline and suspension of the 
heart's sounds and impulse are due not only to the 
weakness of the cardiac muscle, but also to the les- 
sened volume of the circulating blood, is proved by 
the fact that they persist, sometimes for many hours, 
after reaction has commenced, and only become audible 
again when the arteries have been replenished with 
blood. 

In the description of the symptoms of cholera it has 
been mentioned that the cyanotic color of the skin is 
produced by an accumulation of blood in the veins. 
Many years ago Magendie, and after him Dieffenbach, 
on examining the arteries of persons in the advanced 
stage of cholera, found those vessels empty of blood. 
It might be supposed that, under the circumstances, 
not only the right side of the heart, but also the lungs, 
would be gorged with blood, and that extreme dysp- 
noea would result. But, in point of fact, the respiration 
in cholera is hurried and shallow rather than oppressed 
and labored, while after death the lungs are not en- 
gorged with blood, but rather in a bloodless condition. 
The pulmonary artery and its branches are also empty, 
although the right side of the heart may be filled with 
dark and soft coagula. These singular conditions 



74 CHOLERA. 

seem to be due, on the one hand, to the greatly 
diminished mass of the blood in the vessels, and to 
its accumulating and stagnating in various parts of the 
venous system, and, on the other hand, to the weakness 
of the heart, which is shown by its suppressed impulse 
and sounds, and which lessens its power to propel the 
venous blood into the lungs. The infarction of the 
systemic veins and the threatening suspension of the 
circulation necessarily impair the activity of all the 
functions, including those of nutrition and disintegra- 
tion, so that the effete detritus of the economy tends 
to accumulate in the blood. This tendency is doubt- 
less counterbalanced not only by the diarrhoea, but 
also, more or less, by the almost total suspension of 
nutrition, due to the inability of the cholera patient to 
digest or even to retain food, as well as by the dimin- 
ished oxidation of the blood in the lungs. It has 
already been observed that, to a certain extent, the 
impediment to the passage of the blood from the right 
side of the heart into the ramifications of the pulmo- 
nary artery tends to prevent congestion and infarction 
of the lungs. But this obstruction is precisely what 
occurs during the stage of reaction in many cases, 
which then terminate fatally by asphyxia, as in the 
previous stage still more perish by apncea. 

In the milder attacks of cholera vomiting may not 
occur, and in the most severe it not unusually is sus- 
pended for some time before death, although the diar- 
rhoea may continue. In the most malignant cases, 
indeed, there may be no vomiting at all, in conse- 
quence of the extreme muscular exhaustion, although 
the stomach may be distended with liquid. When 



COMPLICATIONS AND SEQUELJE. 75 

rejected, the liquid has the general aspect of rice-water, 
which the stools also present. Its reaction is alkaline 
or neutral, and it is said to contain a less proportion 
than the stools of solid matter, but a larger proportion 
of urea. The act of vomiting is strictly one of regurgi- 
tation, which is performed without effort or pain. Some- 
times, indeed, it seems to relieve the sense of weight 
caused by the accumulated contents of the stomach. 
It is readily excited by attempts to drink, and even by 
slight changes of posture. The vomited liquid at first 
contains the various articles of food the patient may 
have eaten. Their half-digested remains have some- 
times suggested the announcement of strange specific 
forms of cholera-germs. The liquid, after ceasing to 
be colored brownish or greenish, becomes gray, and 
subsequently, in favorable cases, more or less green 
again ; while during the stage of reaction in grave 
and ultimately fatal cases it is more or less reddened 
by an admixture of blood. Its most usual and charac- 
teristic appearance is that of a grayish liquid contain- 
ing whitish flocculi. The nature of this liquid, whether 
discharged by vomiting or by purging, has been vari- 
ously estimated. Formerly, some persons held the 
white granules to be leucocytes, but the greater num- 
ber agree that they are merely epithelial fragments. 
When the vomited liquid is allowed to stand, a sedi- 
ment forms in it which is composed almost entirely of 
epithelial scales, more or less modified in their appear- 
ance by the accidental contents of the stomach, and a 
film covers its surface in which globules of fat and 
phosphatic crystals may be detected. They are fre- 
quently associated with sarcinae, produced by fer- 



y6 CHOLERA. 

mentation in the contents of the stomach, and after 
standing for some time the liquid becomes crowded 
with vibrios (Lindsay). 

Although the propensity of the sick to discover a 
cause for every symptom often leads cholera patients 
to attribute their diarrhoea to some particular exposure 
to cold, error of diet, etc., yet, in fact, this symptom, so 
far as it belongs to cholera, is primarily an effect of the 
cholera-poison alone, although it may be aggravated 
by causes like those mentioned. It is of great prac- 
tical importance to bear in mind that a specific chol- 
eraic diarrhoea —that is to say, a diarrhoea produced by 
the cholera-poison alone — may continue to be very 
slight as long as it lasts, which may be for several 
weeks ; and hence, as elsewhere insisted upon, a per- 
son who is not suspected of being affected with cholera 
may, quite ignorantly, sow the seeds of a deadly epi- 
demic of the disease. The danger in cholera is pro- 
portioned to the volume of the discharges rather than 
to their frequency, just as a single profuse hemor- 
rhage is more serious than the loss of an equal amount 
of blood divided among several successive days. The 
special danger, however, is not, as in hemorrhage, from 
syncope, but from the progressive loss by drainage of 
the water of the blood, rendering it unfit to circulate, 
and therefore causing it to stagnate in the veins. The 
spoliative operation of the diarrhoea has occasionally 
been productive of benefit instead of injury, as in the 
following case of Barlow : A man suffering from 
dropsy was attacked with cholera, " and passed gal- 
lons of liquid by stool, had cramps, and became livid 
and clammy, but his pulse did not disappear, as in 



COMPLICATIONS AND SEQUELsE. 77 

profound collapse, and he eventually rallied, and left 
the hospital apparently well. When he began to 
recover from cholera his appearance was almost lu- 
dicrous, from the manner in which the integument 
hung loosely about him." 

The stools pass through a series of changes corre- 
sponding to those of the matters vomited, being fecal 
at first and then becoming colorless and watery. Dur- 
ing reaction, if that occurs, they regain more or less of 
their proper color, but if typhoid febrile symptoms pre- 
vail they are usually bloody. Decomposed blood some- 
times renders them dark, tarry, and fetid ; this con- 
dition has caused them sometimes to be described as 
being composed of vitiated bile, which is, however, a 
product not of the liver, but of the imagination. 

In the intestine after death considerable quantities 
of epithelium are found floating in the contained liquid 
or else loosely adherent to the mucous membrane. It 
is usually in flocculi, but sometimes in fragments large 
enough to form a continuous membrane. A micro- 
scopic examination of cholera stools shows that their 
turbidness depends chiefly upon desquamated epithe- 
lium, with which are mixed white corpuscles and bac- 
teria. It is remarkable that although the stools are 
drained directly and so rapidly from the blood-vessels, 
they nevertheless contain but little albumen, indeed 
hardly more than a trace of it. If, however, blood is 
mixed with the stools, as happens in rare instances, 
more albumen is present. Oil-globules are most abun- 
dant in cases that have passed beyond the stage of 
collapse into that of reaction with fever. .In these it is 

said that oily matter may be found either in concrete 

7* 



?8 CHOLERA. 

masses or as a scum of liquid oil. Of inorganic con- 
stituents they contain crystals of the triple phosphate 
of ammonium and magnesium and chloride of sodium 
in greatest abundance, but the proportion of ammo- 
nium and potassium salts is small. Indeed, the total 
amount of solids does not exceed 2 per cent. As the 
quantity of water in the blood and solids is limited, and 
as in this disease the stomach will not receive nor re- 
tain any liquid, it follows that the more profuse the 
evacuations are, the shorter must be the duration of the 
attack, for the sooner then does the blood become too 
thick to circulate. 

It has several times been stated that in cholera the 
urine is diminished, and that, therefore, the blood re- 
tains a larger proportion of effete products than in 
health. But it has also been remarked that the amount 
of these products is abnormally small, on account of 
the interference with nutrition of the abnormal state of 
the circulation. Doubtless, as in other cases of renal 
obstruction, an increased proportion of effete matter is 
eliminated by the skin, if not by the bowels. When 
the amount of urine excreted is only diminished, its 
specific gravity may vary between remote extremes, as 
1.012 and 1.030. Usually, however, when its quantity 
is very greatly reduced, symptoms which are described 
as ursemic are apt to arise, and the urine is found to 
contain the usual products of renal congestion — viz. 
albumen, sometimes traces of blood, hyaline and gran- 
ular casts, and epithelial scales, with less chloride of 
sodium and more urea than normal. It is remarkable 
that at the beginning of convalescence the urine, which 
had been suppressed or greatly diminished, may be- 



COMPLICATIONS AND SEQUELS. 79 

come for a time abnormally abundant. Rarely, if ever, 
does the derangement of the kidneys now described 
denote or produce an organic lesion in those organs. 
Like the disorders elsewhere, these are due to the loss 
of balance between the arterial and the venous sides of 
the circulation ; both, indeed, have lost their functions 
more or less, the one by lack of blood, the other by an 
excess of blood unfit for circulation. 

The occurrence of cramps in cholera, which has be- 
stowed upon the disease one of its titles, spasmodic, 
has, however, no distinctive relation to the Asiatic dis- 
ease. Spasmodic phenomena occur in many cases of 
poisoning by corrosive and irritant agents and in ordi- 
nary cholera morbus, and in cholera infantum they are 
among the most alarming symptoms, assuming, as they 
often do, the character of general convulsions. In most 
of these cases they are clonic and general, and therefore 
probably of central origin, primary or reflected ; but the 
spasms of cholera are tonic, and affect the muscles of 
the upper and lower limbs, and most frequently the 
flexor muscles of these parts, and especially those of 
the fingers and toes, which become rigidly bent. The 
larger muscles contract into hard lumps, and even those 
of the chest and abdomen do not escape the terrible 
spasms. When they are severe they extort cries from 
patients who at other times seem quite apathetic. It is 
stated by Macnamara that the natives of Southern Ben- 
gal and other people of relatively loose fibre are much 
less apt to be attacked by them than the natives of the 
upper country or than Europeans. It may be debated 
whether their immediate cause is a reflex irritation 
emanating from the gastro- intestinal mucous mem- 



80 CHOLERA. 

brane ; or whether it is due to the rapid diminution 
of the supply of blood to the nervous centres, or to 
the infarction of those centres with thick and imper- 
fectly oxygenated blood ; or, finally, whether it is occa- 
sioned by a diminished supply of blood, and that blood 
of bad quality, to the muscles themselves. Probably 
all of these factors are associated causes in producing 
the spasmodic phenomena of cholera. It is well worthy 
of notice, however, that spasms, which are so frequent 
in all infantile diseases, and especially in those affecting 
the stomach and bowels, rarely attack children suffer- 
ing from cholera. This would seem to prove that the 
spasms in question are not reflex, but either central 
and spinal, or else muscular — an inference which is 
strengthened by their being tonic and not clonic. As 
stated, the spasms, or cramps, frequently affect the 
limbs, but comparatively seldom involve the muscles 
of the chest or abdomen, and those of the face hardly 
ever. They are almost the only causes of pain in the 
disease, which in not a few instances runs its whole 
course, even to a fatal termination, without their oc- 
currence. 

As a rule, the abdomen is not so much retracted as 
might be expected from the profuse discharges. Prob- 
ably in some degree its form is maintained by the con- 
stantly recurring accumulation of liquid in the gastro- 
intestinal cavity. In protracted cases, however, the 
abdomen becomes sunken and hollowed. At all stages 
of the disease it is somewhat sore under pressure, espe- 
cially at the epigastrium, and it generally has a doughy 
feel. As to the functions of the digestive organs, they 
are completely suspended during a typical attack of the 



MORBID ANATOMY AND PATHOLOGY. 8 1 

disease. Not only are these organs incompetent to 
digest food, but they cannot even retain it. 

Throughout such an attack not only is sleep apt to 
be prevented by the pain of the cramps and the fre- 
quent evacuations, but, as a rule, the patient is wakeful, 
and yet, apart from the restlessness which accompanies 
the paroxysms of pain, there is, on the whole, a tend- 
ency to a placid quietness. Mental excitement and 
delirium are probably unknown during the primary 
attack, but sometimes a degree of somnolence or of 
apathetic tranquillity exists, which, however, is quite 
distinct from coma. When the attack is prolonged, 
and especially when it merges into a typhoid state, the 
eyes become inflamed by their exposure to the air. 
The conjunctiva then grows blood-shot, and occasion- 
ally the cornea is ulcerated. 



MORBID ANATOMY AND PATHOLOGY. 

The appearance after death of a person who has died 
in the collapse of cholera is very characteristic. It 
comprises a shrunken aspect of the whole body, its 
prevalent grayish or leaden pallor contrasting with the 
livid hue of the abdomen and back, the fingers and 
toes, the lips and eyelids, and ears ; the eyes are sunk- 
en deeply in their orbits ; the nose is sharp and bent, 
the temples are hollow, and the skin seems to cling 
tightly to the bones beneath it. The connective tissue 
is very dry, and the muscles are hard as well as dry, 
and, owing to the wasting of the softer parts, stand 
prominently out. In consequence of the absence of 



82 CHOLERA. 

moisture decomposition takes place very slowly. Ca- 
daveric rigidity is very marked and persistent. A very 
notable phenomenon is the occurrence of muscular 
contraction after death. It may be excited mechani- 
cally or may occur spontaneously. A case is related 
(Eichhorst) in which three hours after death the fibres 
of the biceps were observed to move tremulously, and 
then the entire muscle contracted, causing flexion of 
the forearm. Even the fingers performed movements 
like those made in piano-playing. The lower jaw has 
also been observed to move, causing the mouth to open 
and shut repeatedly. The late Sir Thomas Watson 
long ago described this singular phenomenon as fol- 
lows : "A quarter or half an hour, or even longer, after 
the breathing had ceased, and all other signs of anima- 
tion had departed, slight, tremulous, spasmodic twitch- 
ings and quiverings and vermicular motions of the 
muscles would take place, and even distinct move- 
ments of the limbs, in consequence of these spasms." 1 
It was carefully studied by Barlow, from whose narra- 
tive the following is taken : The patient was a strong 
man ; the course of his attack was rapid, and he suf- 
fered most cruelly from cramps. " Within two minutes 
of his ceasing to breathe muscular contractions began, 
becoming more and more numerous. The lower ex- 
tremities were first affected. Not only were the sar- 
torius, rectus, vasti, and other muscles thrown into vio- 
lent spasmodic movements, but the limbs were rotated 
forcibly and the toes were frequently bent. The mo- 
tions ceased and returned ; they varied also : now one 
muscle moved, now many. Quite as remarkable were 

1 Lectures, Am. ed. of 1872. 



MORBID ANA TO MY AND PA THOL OGY. 83 

the movements of the arm : the deltoid and biceps 
muscles were peculiarly influenced ; occasionally the 
forearm was flexed upon the arm — flexed completely, 
and when I straightened it, which I did several times, 
its position was recovered instantly. The fingers and 
thumbs were now and then contracted, and at times 
the thumbs were separately moved. The fibres of the 
pectoral muscles were often in full action ; distinct 
bundles of them were seen at intervals beneath the 

skin After I had taken leave of the body the 

nurse was horrified by a movement of the lower jaw, 
which was followed by others ; and I thought for a 
moment that the man was alive. The facial muscles 
became generally affected, and at length all was still." 1 
These muscular contractions succeed one another in a 
regular order, beginning in one lower extremity and 
extending to the other, then to the upper limbs, and 
finally to the face. Their degree varies from a slight 
quivering to a powerful contraction, and their duration 
from a minute or less to an hour and a quarter. Cases 
have occurred in which the legs were so forcibly re- 
tracted that they could with difficulty be straightened 
again. In one case, six hours after death movements 
took place in one leg, and the hand was drawn across 
the chest ; in another, " the forearms were powerfully 
flexed, and the hands, approximating, gave the attitude 
of praying to the body." 2 Again, Mr. Ward reports: 
" I saw the eyes of my dead patient open and move 
slowly in a downward direction. This was followed, a 
minute or two subsequently, by the movement of the 

1 London Med. Gaz., Nov., 1849, P- 79^- 

2 Ibid, Jan., 1850, p. 185. 



84 CHOLERA. 

right arm (previously lying by the side) across the 
chest." In the same paper Barlow says : " Mr. Law- 
rence mentioned to me that a gentleman who died in 
1832 of rapid cholera was turned after death complete- 
ly on the side by a strange and forcible combination 
of muscular contractions." 1 These muscular pheno- 
mena after death form an interesting feature in the his- 
tory of cholera, but they are by no means peculiar to 
that disease. They have been observed in other diseases, 
and especially in yellow fever — an affection in which 
the pathological condition is quite unlike that of chol- 
era. In both cases they have been manifested in robust 
persons and when the course of the fatal attack was 
both rapid and severe. Thus, Dr. Dowler of New 
Orleans not only found that they could be developed 
in such cases of yellow fever by striking the muscles, 
but he observed their spontaneous occurrence in sev- 
eral, of which the following is a remarkable example : 
" Not long after the cessation of the respiration the left 
hand was carried by a regular motion to the throat, and 
then to the crown of the head ; the right arm followed 
the same route on the right side ; the left arm was then 
carried back to the throat, and thence to the breast, re- 
versing all its original motions, and finally the right 
hand and arm did exactly the same." 2 In i860, 
Drasche alleged that not unusually the skin covering 
the contracting muscles became reddish, while the local 
temperature rose j4°, and that as soon as the contrac- 
tions ceased the temperature fell below the normal and 
cadaveric rigidity set in. According to the same ob- 

1 London Med. Gaz., Jan., 1850, pp. 185, 186. 

2 Experimental Researches, 1846. 



MORBID ANA TO MY AND PA THOL OGY. 85 

server, analogous contractions affect the unstriped mus- 
cular fibres, in those of the skin producing a projec- 
tion of the papillae, and in the genital organs a dis- 
charge of semen. This phenomenon is said to have 
occurred an hour and a half after death. 

On opening the abdominal cavity of persons who 
have died in the collapse of cholera one is struck by 
the general pink or rose tint of the peritoneal coat of 
the intestines. It is produced by a repletion of the 
minute branches of the portal venous system. Some- 
times the color is rendered very dark by the pitchy 
blood contained in the veins. The surface of the 
peritoneum, like all the tissues, is singularly dry, and 
often has a soapy or sticky feel, caused by a layer of 
albuminous matter, which forms a lather when rubbed 
between the fingers and causes the intestinal folds to 
adhere to one another. If death takes place during the 
stage of reaction, these appearances are less distinct, 
and the intestines, which in collapse are usually re- 
tracted, are then somewhat distended. 

The stomach generally contains a thin, partially 
transparent liquid of a greenish or grayish color, and 
occasionally reddish, holding in suspension portions 
of coagulated mucus and an unctuous substance of an 
albuminous nature, which adheres to the walls of the 
cavity. Fatty globules may be observed floating in 
the liquid, which under the microscope reveals epithe- 
lial debris, granular corpuscles, and fragments of gas- 
tric glands. Under heat and nitric acid coagulation 
of the liquid occurs, and on chemical examination it is 
found to contain urea. The gastric mucous membrane 
is of a dark-violet or pale-pink color, according to the 
8 



86 CHOLERA. 

stage of the disease ; its follicles are enlarged, and 
patches of superficial abrasion may be observed on it. 
The intestinal canal of those who die during the 
collapse of cholera is, in the majority of cases, partially 
filled with liquid which has the aspect of turbid serum, 
more or less mixed with the previous contents of the 
bowel if death has taken place very rapidly, but other- 
wise it is almost colorless. On the whole, however, it is 
less pale and watery than the stools. It contains, like 
these discharges, more or less epithelial flocculi, and 
generally more than were observed during life in the 
dejections. The mucus scraped from the lining mem- 
brane of the intestine and mixed with water renders it 
turbid with epithelial debris. The same mucus ex- 
amined microscopically contains fragments, larger or 
smaller, of epithelium. These conditions are said to 
predominate in the large intestine. Indeed, the pro- 
portion of liquid increases from above downward. 
Hence in the more prolonged cases the contents of 
the bowel at its upper part are less liquid and are 
darker in color. There is, indeed, a striking contrast 
between the appearance of the intestine in cases which 
have terminated in collapse and its aspect in persons 
who have died during the stage of reaction. It has 
been clearly presented by Dr. Sutton. 1 When death 
took place in " the cold stage the mucous membrane 
was unusually pale in three cases ; in two it was 
healthy-looking ; in other two it was pale through- 
out, excepting that one or two of Peyer's patches were 
congested ; and in the remaining three there was more 
or less congestion of the mucous membrane. When 

1 London Hosp. Clin. Led. and Reports, iv. 497. 



MORBID ANA TO MY AND PA THOL OGY. 87 

the mucous membrane was pale throughout the entire 
intestine, the valvulae conniventes looked swollen and 
cedematous, and the color of the membrane was dead 
white. The solitary glands were very distinct and 
prominent. Those of the duodenum were remarkably 
so. In cases of imperfect reaction the mucous mem- 
brane of the intestine was usually found very much 
congested and ecchymosed. The congested portions 
were sometimes granular, and apparently denuded of 
epithelium. The mucous surface had often a dark 
port-wine color, due to the extravasated blood and the 
hyperaemia, and here and there the surface was cov- 
ered with a dirty gray membranous substance, likened 
to a diphtheritic deposit. I have, however, seen no 
decided false membrane, such as could be peeled off, 
as in diphtheria. The surface was also occasionally 
bile-stained, and the greenish-yellow color of the bile 
and the deep-red color of the congested surface pre- 
sented a very striking appearance. The solitary glands 
were very prominent, and in some cases apparently 
enlarged." The general paleness of the intestinal 
mucous membrane in the stage of collapse, and its 
congestive redness whenever the signs of reaction have 
existed before death, have a very important bearing 
upon the pathology of this disease, for they demon- 
strate conclusively that the gastro-intestinal evacua- 
tions in cholera have no relation whatever to 
inflammation. On the other hand, they render it 
altogether probable that the serous flux is in the 
nature of a sweat, an intestinal ephidrosis. 

The nature of the exfoliation found in the intestinal 
canal has been the subject of much discussion. As 



88 CHOLERA. 

long ago as the first American epidemic of cholera 
(1832-35) Dr. W. E. Horner, Professor of Anatomy in 
the University of Pennsylvania, described an exfolia- 
tion of the epithelial lining of the alimentary canal, 
whereby the extremities of the venous system of the 
part are denuded, as being characteristic of cholera 
alone. In 1849, Dr. Samuel Jackson, Professor of the 
Institutes of Medicine, and Dr. John Neill, Demon- 
strator of Anatomy, in the University, in conjunction 
with Dr. William Pepper and Dr. Paul B. Goddard, 
presented a report to the College of Physicians of 
Philadelphia, in which they, too, showed that the 
" epithelial layer of the intestinal mucous mem- 
brane was either entirely removed or was detached, 
adhering loosely." This important fact — the most 
important, perhaps, in the mechanism of cholera — 
was confirmed seventeen years later by the eminent 
pathologist Dr. Lionel S. Beale, 1 who, when referring 
to "the remarkable characters of the matter discharged 
from the intestinal tube, and to the fact that the small 
intestines almost always contain a considerable quan- 
tity of pale almost colorless gruel-, rice-, or cream-like 
matter," added : " This has been proved to consist 
almost entirely of columnar epithelium, and in very 
many cases large flakes can be found, consisting of 

several uninjured epithelial sheaths of the villi 

In bad cases it is probable that almost every villus, 
from the pylorus to the ilio-caecal valve, has been 

stripped of its epithelial coating during life 

These important organs, the villi, are, in a very bad 
case, all, or nearly all, left bare, and a very essential 

1 Med. Times and Gazette, Aug., 1 866, p. 109. 



MORBID ANATOMY AND PATHOLOGY. 89 

part of what constitutes the absorbing apparatus is 

completely destroyed It is probable that the 

extent of this process of denudation determines the 

severity or mildness of the attack It seems 

probable also that the epithelium may become de- 
tached in consequence of the almost complete cessa- 
tion of the circulation in the capillaries beneath, but 
the death of the cells may occur in consequence of 
their being exposed to the influence of certain matters 
in the intestine or in the blood, in which case they 
would simply fall off." 

In this connection, and as complementary of the 
statements now made, should be considered the further 
description by the same author — viz. : " Remarkable 
changes have occurred in the smaller vessels, espe- 
cially in the capillaries and small veins of the villi 
and submucous tissue. The blood-corpuscles appear 
to have in a great measure been destroyed in the 
smaller vessels, and in their place are seen clots con- 
taining blood-coloring matter, minute granules, and 
small masses of germinal matter evidently undergoing 
rapid multiplication. Some of the arteries are con- 
tracted, but here and there small clots destitute of 
blood-corpuscles may be seen at intervals." Hence 
the gastro-intestinal lesions in cholera ; according to 
their extent and degree they remove the natural ob- 
stacles to exhalation in the mucous membrane, and 
also, and in the same degree, prevent the absorption 
of the contents of the alimentary canal. It must not, 
however, be forgotten that this lesion is not altogether 
peculiar to the intestinal mucous membrane. Dr. Beale 
long ago called attention to the fact that in this disease 

8* 



90 CHOLERA. 

there seems to be a tendency to the removal of epithe- 
lium from the surface of all soft, moist mucous mem- 
branes, but not from the follicles of the glands. The 
first statement appears to be explicable by the shrink- 
age of all the mucous membranes during cholera col- 
lapse, for by this merely mechanical agency the inelastic 
epithelium must necessarily become detached. As to 
the second statement, the remark may be made that 
the whole follicular surface furnished with columnar 
epithelium is an absorbing and not an eliminating 
apparatus, and that, since its functional activity is 
from the beginning of the disease diminished by an 
inadequate blood-supply, it can have but a small and 
indirect share in generating the phenomena of the 
disease. 

In his original report on the cholera in Egypt, 1 Dr. 
Koch describes those bacteria of a definite form which 
have since been so closely associated with his name. 
The following is his account of them : " They are rod- 
shaped, and belong, therefore, to the bacilli ; in size 
and shape they most nearly resemble the bacilli found 
in glanders. In those cases in which the bowel showed 
the slightest changes to the naked eye the bacilli were 
found to have penetrated into the follicular glands of 
the mucous membrane, and had there given rise to 
very considerable irritation, as shown by the increase 
of the lumen of the gland and the collection of many 
nucleated cells in its interior. In many cases the ba- 
cilli had also penetrated behind the epithelium of the 
glands, and had proliferated between it and the base- 
ment membrane of the gland. They had, moreover, 

1 Times and Gaz., October, 1883, p. 447. 



MORBID ANA TO MY AND PA THOL OGY. 9 1 

collected in considerable quantities on the surface of 
the villi, and had often penetrated into their substance. 
In severe cases which had been characterized by hem- 
orrhagic infiltration of the intestinal mucous membrane 
the bacilli were found in large numbers, and were not 
limited only to the interior of the follicular glands, but 
had passed into the surrounding tissues, into the deeper 
layers of the mucous membrane, and here and there 
even into the muscular coat of the bowel. The villi 
were also in such cases extensively invaded by the ba- 
cilli. The chief seat of these changes is the lower 
part of the small intestine." 

In 1884, Dr. Koch, during his investigations of chol- 
era in India, found the same bacilli in the bowel which 
he believed to be peculiar to the disease, and which 
presented the following characters : they were not 
straight, like other bacilli, but curved or comma- 
shaped ; they proliferated rapidly and displayed very 
active movements. Bodies of persons who died of 
various other diseases did not present them, although 
abounding in different bacteria. The bacilli were not 
found, or only exceptionally, in the stomach, but 
abundantly in the intestine, and most so in the diar- 
rhceal discharges that occurred at the height of the 
disease. As soon as the stools began to be fecal the 
specific bacilli disappeared from them. After death at 
the height of the disease they were most abundant in 
the intestinal contents, and especially in the lower part 
of the small intestine. When death took place at a 
later period none of them might be detected in the 
liquids in the bowel, but they would still be present, 
in considerable numbers, in the tubular glands. They 



92 CHOLERA. 

were not found at all in cases fatal from some sequela 
of the disease. 1 

The conclusions of these two reports, and of the 
much more detailed descriptions presented by Dr. 
Koch to the conference held at Berlin in July, 1884, 2 
are substantially identical, and, although they have 
generally been accepted as furnishing a solid founda- 
tion for a pathology of cholera, they are by no means 
assented to by other observers even in the same field 
in which Dr. Koch conducted his researches. The 
most important document relating to the question is a 
Report presented by Drs. E. Klein and Heneage Gibbes 
to the government of India. Its conclusions are as 
follows: "(1) The statement of Koch that 'comma 
bacilli ' are present only in the intestines of persons 
suffering from or dead of cholera is not in accordance 
with the facts, since ' comma bacilli ' occur also in 
other diseases of the intestines; e.g. epidemic diarrhoea, 
dysentery, and in intestinal catarrh associated with 
phthisis. (2) The ' comma bacilli ' in acute typical 
cases of cholera are by no means present in such num- 
bers and with such frequency as to justify Koch's 
statement that the ileum contains almost a pure culti- 
vation of ' comma bacilli.' (3) The ' comma bacilli ' 
are not present in the tissue of the intestine or else- 
where. (4) The ' comma bacilli ' in artificial cultiva- 
tions carried out by one of us (E. K.) do not behave 
in any way differently from other putrefactive organ- 
isms. (5) Mucus-flakes of the ileum, taken out soon 
after death from typical acute cholera, contain numer- 

1 Times and Gaz., Mar., 1884, p. 398. 

2 Med. News, xlv. 221. 



MORBID ANATOMY AND PATHOLOGY. 93 

ous mucus corpuscles, many of them filled with pecu- 
liar minute straight bacilli. The same bacilli occur 
also outside the mucus corpuscles. They are never 
missed even when the ' comma bacilli ' are. (6) These 
small bacilli have been cultivated by one of us (E. K.), 
and they do not behave differently from putrefactive 
organisms. These small bacilli are not present in the 
tissues of the intestines or any other tissue. (7) No 
bacteria of any kind, and no organisms of known form 
and character, occur in the blood or any other tissue. 
(8) A good many experiments have been carried out 
by one of us (E. K.), with the following results : (a) 
Mice, rats, cats, and monkeys were fed with rice-water 
stools, with vomit, with mucus-flakes of the ileum, 
fresh and after having been kept for twenty-four to 
forty-eight hours. The animals remained normal, (b) 
Inoculations with recent and old cultivations of ' comma 
bacilli,' as well as with mucus-flakes, were made into 
the subcutaneous tissue, into the peritoneal cavity, into 
the jugular vein, and into the cavity of the small and 
large intestine of rabbits, cats, and monkeys ; but the 
animals remained perfectly well and normal." l In 
confirmation of these conclusions may be cited those 
of Mr. Timothy Richards Lewis, who under peculiarly 
favorable circumstances studied the relations of the 
" comma bacillus " to cholera at Marseilles during the 
epidemic of 1884. He shows that " comma-like ba- 
cilli, identical in size, form, and in their reaction with 
aniline dyes, with those found in choleraic dejecta, are 
ordinarily present in the mouth of perfectly healthy 
persons." 2 At a still more recent date .than the pre- 

1 Med. Times, Jan., 1885, p. 31. 2 Ibid., Sept., 1884, p. 398. 



94 CHOLERA. 

ceding x Dr. Klein, with the aid of Dr. Gibbes and Mr. 
Lingard, published the final results of their investiga- 
tion, confirming in all respects their earlier announce- 
ment ; and among their conclusions is the very im- 
portant one, insisted on elsewhere, that the earlier after/j 
death the examination is made the fewer " comma ba- 
cilli " were found, or, in other words, that the bacteria 
are not causes, but consequences, of the disease. In- 
deed, the mucous membrane of the ileum, in typical 
rapidly fatal cases, if examined soon after death, does 
not contain in any part any trace of a " comma bacil- 
lus." Dr. Dowdeswell, also after a critical and experi- 
mental investigation of the question, agrees with the 
second report of Dr. Koch in the conclusion that, 
" though the microbe bears some relation to the dis- 
ease, it is not its actual cause." 2 

At the conclusion of a series of lectures on the 
morbid anatomy of cholera, M. Strauss, who was the 
chief of the French Cholera Commission in Egypt in 
1883, combated the views of Dr.' Koch. " If," he said, 
" the comma bacillus was the true cause of cholera, it 
presented the very strange peculiarity of possessing 
the property of provoking such grave symptoms, and 
such profound alterations in the blood, kidneys, etc., 
merely by its presence in the contents of the intestines, 
since it was never met with in the blood or viscera, and 
— in rapid cases, at any rate — it did not even invade 
the intestinal mucous membrane in any considerable 
degree. This would create for it in the history of 
pathogenic microbes a place quite special. ... If the 

1 British Med. Jour., February, 1885. 

2 Ibid., March, 1885, p. 589. 



MORBID ANA TO MY AND PA THOL OGY. 95 

comma bacillus were really pathogenic, and not simply 
a common organism which multiplied abundantly in 
the intestines of cholera patients because it found there 
a suitable cultivation medium, it would be necessary to 
show that it was only met with with the characteristics 
peculiar to it exclusively in cholera. . . . After refer- 
ring to the discovery of comma bacilli in chronic dys- 
entery by M. Malassez and in healthy saliva by T. R. 
Lewis, and to the manner in which Koch had dealt 
with the objections thus raised, M. Strauss spoke of 
the observations of MM. Finkler and Prior. The latter 
had met with an epidemic of cholera nostras at Bonn, 
and in the stools of one of the patients they had found 
an organism morphologically identical with that of 
Koch, and which by cultivation gave rise to spirillae. 
They had forwarded a specimen of their organism to 
M. Pasteur, and thus he (M. Strauss) had had the op- 
portunity of studying and cultivating it. Morpholog- 
ically, it was impossible to find the slightest appreciable 
difference between the organism of Messrs. Finkler 
and Prior and the comma bacillus." l It is unnecessary 
to analyze in detail the preceding experiments and ob- 
servations. They are sufficiently harmonious to war- 
rant the belief that the essential cause of cholera is not 
the comma bacillus, and to sustain the conclusion 
which we have arrived at in a subsequent paragraph 
of this dissertation. 

Other abdominal lesions in cholera possess a very 
subordinate importance. The isolated and the agmi- 
nated glands are both prominent, chiefly because they 
are swollen by the liquid imbibed from the bowel. A 

1 Times and Gazette, April, 1885, p. 523. 



96 CHOLERA. 

whitish substance which they sometimes contain may 
perhaps be the albumen or fat which they have taken 
from the intestinal liquid. A very similar condition 
of the mesenteric glands is probably due to a like 
cause. The liver is pale and flaccid when death takes 
place in collapse, and it is also described as presenting 
a " dirty grayish-red, homogeneous appearance, and 
indistinctness of the lobular structure, as if some glu- 
tinous matter had been poured throughout the tissues 
of the organ " (Sutton). This appearance would seem 
to be due to the total suspension of the blood-supply 
through the portal vein. 

At all stages of the disease the gall-bladder is usu- 
ally found full of bile, which is apt to be dark during 
the collapse and more watery after reaction has com- 
menced. 

The spleen is small, pale, and, as a rule, firm, but 
occasionallv it is soft. 

The kidneys present no marked changes when death 
has taken place early in the attack, or at most only 
exhibit a lighter color than usual of the cortical sub- 
stance and a darker one of the pyramids. They show 
that the arteries are comparatively empty and that the 
veins are congested. Similarly contrasted appearances 
are met after death from obstructive disease of the 
heart and other causes that produce obstruction of the 
venae cavae. In the tubules, later on, fatty degenera- 
tion of the epithelium has been observed, and some 
cylindrical casts. These alterations, especially of the 
tubules, are most marked when death occurs in the 
stage of reaction, and are then apt to be accompanied 
by more or less hemorrhagic transudation. The uri- 



MORBID ANA TOM Y AND PA THOL OGY. g? 

nary bladder is always contracted after death in col- 
lapse ; after febrile reaction its mucous membrane may 
be more or less coated with false membrane. 

The brain and the spinal marrow offer nothing- pecu- 
liar ; their venous systems are everywhere more or less 
engorged, and sometimes effused blood has been found 
in the spinal canal. 

In the state of the respiratory organs the most im- 
portant facts are that in algid cholera the lungs are 
always more or less collapsed, " shrunk, and small, and 
lying back in the chest, toward the spine," and that, so 
far from being congested, they are (with the exception 
of a small portion of their posterior part rendered 
dense by hypostasis) singularly bloodless, dry, and 
tough. As might be inferred from these conditions, 
they are also lighter in weight than natural. To Dr. 
Parkes belongs the credit of having first described this 
very important fact in the morbid anatomy of cholera, 
as follows : " In fourteen cases the lungs were com- 
pletely collapsed, appearing in some cases like the 
lungs of a foetus. In three cases they were considera- 
bly, in eight slightly, collapsed, and in the remaining 
fourteen cases the collapse was in some altogether, and 
in some partially, prevented by old adhesions." l So 
Dr. Sutton found that the average weight of the two 
lungs during collapse was about twenty ounces, and 
after reaction — that is, after the passage of the blood 
into the pulmonary artery had become completely re- 
established — about forty-five ounces. In the latter 
condition also the lungs presented the usual signs 
of congestion of those organs, being dark-red through- 

1 Med. Times, 1848, p. 378. 



98 CHOLERA. 

out or in portions only. Sometimes also they con- 
tained masses or nodules of apparent hepatization, 
and of these some may have undergone partial 
softening. 

In absolute conformity with the condition of the 
lungs that has been described is that of the heart. If 
the lungs are bloodless, it follows necessarily that the 
left side of the heart must be empty, and almost as 
necessarily that the right side of the heart must be 
distended with blood. All careful investigators of the 
subject agree that such is the condition of the heart 
when death takes place in cholera during the stage of 
asphyxia. All report that the pulmonary artery is 
either empty or that it contains a small quantity of 
dark and usually of thick blood; that the right side of 
the heart and the coronary veins are distended with 
blood of the same description, while numerous ecchy- 
moses exist along the course of the coronary veins ; 
that the venae cavae are filled with half-coagulated 
blood of a tarry aspect ; and that even the femoral and 
splenic veins contain similar blood. On the other 
hand, the left ventricle of the heart is usually contract- 
ed, and contains a very little semi-fluid blood, with 
perhaps a small and pale clot. This engorged condi- 
tion of the right cavities and emptiness of the left cavi- 
ties of the heart diminish very slowly during the pas- 
sage from collapse to reaction, during which time the 
pulmonary blood-vessels are being gradually replen- 
ished. Besides the thick and tarry aspect of the blood 
above described, it has been observed that when the 
blood is withdrawn by means of a pipette, its globules 
rapidly subside and are surmounted by a transparent 



MORBID ANATOMY AND PATHOLOGY. 99 

serum, and that such blood may remain for a long 
time uncoagulated. The red corpuscles are said to be 
pale and viscous, but not adhesive, and the white cor- 
puscles abnormally numerous and easily crushed. In 
the free intervals are observed " very pale little objects, 
slightly elongated and constricted in their middle," 
which multiplied in blood kept for one or two days at 
a temperature of 68° C. (100.4 F.). 1 If death does 
not take place until reaction is far advanced or has 
merged into a febrile condition, the left ventricle is 
usually found not contracted, and it contains a quan- 
tity of blood. The term " usually " is employed to 
show that even to this rule there are some exceptions, 
and that, as in all other diseases, the issue does not 
depend absolutely and exclusively upon a definite de- 
gree of any anatomical lesion, but upon the aggregate 
condition of all the functions upon which life depends. 
The pericardium, like the pleura and the peritoneum, 
may be covered with a saponaceous film which is 
albuminous. 

In looking now over the field that has been trav- 
ersed in the foregoing pages, and searching for some 
link that will unite in a consistent whole the causes, 
symptoms, and lesions of cholera, it is evident that 
only one factor can possibly be so described. That 
factor is the gastro-intestinal flux. This it is that pro- 
duces the vomiting and the purging ; that prostrates 
the patient and wastes away in a few hours the fullest 
and the firmest form ; that chills the limbs and after- 
ward the trunk ; that thickens the blood so that the 
capillary vessels can no longer convey it, and that 

1 Rapport sur le Cholera d 'Egypt e en 1883, par M. le Dr. Strauss, etc. 



100 CHOLERA. 

spreads a cyanotic shadow over the whole surface of 
the body ; that cuts off the supply of blood from the 
lungs and heart; that paralyzes the nervous system, 
ganglionic as well as cerebro-spinal ; that obstructs the 
kidneys and arrests their secretion ; and that, acting 
through the several links of this pathological chain, 
becomes the cause of death. But the question still 
recurs, What is the cause of the gastro-intestinal flux? 
To this also, in the light of observation, it is possible 
to give only one answer. It is a specific poison which 
originates in Hindostan, and, being taken into the 
stomach and bowels, not only produces in the indi- 
vidual the symptoms and lesions of cholera, but is 
capable of multiplying itself and rendering infectious 
the discharges from the stomach and bowels of the 
subjects of the disease, so that it may be transmitted 
from one person to another round the whole circum- 
ference of the globe. Regarding the form and nature 
of that poison little or nothing is definitely established, 
beyond what has already been stated as the result of 
Koch's observations. As far as they go, they har- 
monize with a long-prevalent opinion that the cholera- 
poison consists of certain microscopic germs, which, 
on being received into the bowels, propagate their 
kind and destroy the epithelium. It is believed by 
some that these bodies are products of the rice-plant 
on the banks of the Ganges, and that, having once 
originated the disease, the germs contained in the dis- 
charges become mixed with water or are borne upon 
the wind, and enter the system of new victims, who, 
in their turn, disseminate the plague. This theory will 
be further considered below. 



MORBID ANATOMY AND PATHOLOGY. 10 1 

Another view, that of B. W. Richardson, is that, 
" as pus undergoes changes which convert it into a 
septic poison, so the excreted matter from the aliment- 
ary canal is equally capable, under peculiar conditions 
of oxidation, of producing an alkaloidal organic poison, 
which, soluble in water, but admitting of deposit on 
desiccation," becomes the agent for disseminating the 
disease. In these theories a false datum and a hypoth- 
esis are offered us in place of the fact which we seek. 
The cryptogamous nature of the essential cause of the 
disease has no positive proof, but only the probability 
of coincidence, in its favor. There is no proof, because 
one after another organic form has been alleged to be 
the essential generator of the disease, and each has 
been proved to be either not peculiar to cholera or 
has been shown to be present in other diseases than 
cholera. 

At the present time (1885) it is the fashion to trace 
every disease to specific bacteria or analogous organ- 
isms. But it may be that the occurrence of cholera 
only furnishes the occasion for the development of 
these organisms, just as a certain temperature, hygro- 
metric condition, and deficient light and air will cause 
mould to form on bread and other organic substances. 
Long before the researches made by Dr. Koch others 
had been undertaken which foreshadowed his results. 
In 1849 a committee of the Bristol Medico-Chirurgical 
Society investigated the nature of cholera by means of 
microscopical observations, and discovered in the de- 
jections, and described, bodies which are now known 
as " cholera bacilli." A report on behalf of the com- 
mittee was made by Drs. Baly and Gull, who, however, 
9* 



102 CHOLERA. 

refused to recognize in these bodies a constant or cha- 
racteristic constituent of the ejecta. 1 But within the 
same year 2 Dr. Budd is said to have claimed for these 
bodies a distinct relation to cholera, and his reviewer 
concludes that " they exist in cholera discharges, and 
not elsewhere." As they are figured by the original 
observers they certainly bear some likeness to Koch's 
bacilli. It appears, also, that the late Professor Pacini 
of Florence published in 1854 an account of the lesions 
found in cholera, in which he declared that " the epi- 
thelial lesion is covered by nothing but a very simple 
organism of extreme tenuity, which I shall call ■ mi- 
crobe ' — a term generic and modern — and, with special 
reference to the disease in question, ' cholerigenous 
microbe.' " It is not certain, however, that this mi- 
crobe was identical with that of Koch. The judg- 
ment pronounced by Dr. Beale in this question as 
long ago as 1866 appears now, as it did then, to ap- 
proach the truth upon this point : " There is no 
good reason for supposing that the bacteria in such 
numbers in the alimentary canal in cholera have any- 
thing to do with this disease or with the falling off of 
epithelium from the intestinal and other mucous mem- 
branes. Bacteria are developed in organic matter 
which is not traversed and protected by the normal 
fluids of the body, and they invade. the cells and text- 
ures in cholera after those cells and textures have un- 
dergone serious prior changes, just as they would 
invade textures removed from the body altogether. 
Nor would it be in accordance with known facts to 

1 British Med. Jour., March, 1885, p. 589. 

2 Med. Times, ii. 



MORBID ANA TOMY AND PA THOL OGY. 1 03 

infer that cholera was due to the invasion of some 
peculiar form or species of bacterium." * 

We repeat, then, that while nothing can be simpler 
than the mechanism of cholera viewed as a gastroin- 
testinal hyperidrosis, nothing is more mysterious than 
the mechanism of the primary cause which gives rise 
to it. That its real nature has been correctly described 
is rendered all the more probable by the fact, presently 
to be insisted upon, that sporadic cholera morbus, which 
is always the consequence of a direct irritation of the 
gastro-intestinal mucous membrane, is often with diffi- 
culty distinguishable from Asiatic cholera, which, in- 
deed, differs from the former disease chiefly by the 
intensity of its cause as measured by the gravity of 
its symptoms and by the nature of the special agent 
that produces it. 

The above views regarding the mechanism of chol- 
era were substantially indited before the Egyptian epi- 
demic of 1883, but they are in accord with the more 
definite conclusions arrived at by the German and 
French commissions on the subject. Before their 
reports appeared, however, a communication was made 
by Dr. Kartulis of the Greek hospital in Alexandria, 
setting forth that the drinking-water and the stools 
and blood of the cholera patients contained, the first 
a mass of micro-organisms, and the others bacteria 
and micrococci, which, however, presented no distinc- 
tive characters. 2 The German report was prepared by 
Dr. Koch, the French by Dr. Strauss. 3 The former, 

1 Times and Gazette, Aug. 1866, p. 167. 

2 Medical News, xliii. 377. 

3 Archives gen., Dec. 1883, pp. 713, 722. 



104 CHOLERA. 

alluding to the enormous quantity of micro-organisms 
found in the contents of the bowels and in the stools, 
did not perceive any connection between them and the 
phenomena of the disease. On the other hand, he did 
assign this relation to a species of bacterium found in 
the walls of the intestine, and which he compared to 
the bacilli of glanders. As above related, they were 
lodged within the intestinal glands and behind their 
epithelium, as well as upon the surface of the villi 
and within them, and sometimes even in the muscular 
coat. They were most numerous at the lower end 
of the small intestine. Dr. Koch concluded that al- 
though these bacilli, beyond doubt, are in some manner 
associated with the development of cholera, they are 
by no means slwwn to be its cause \ and may indeed be 
tlieniselves the product of the morbid conditions belonging 
to cholera. All his attempts at that time to develop 
cholera in animals by inoculating them with the organ- 
isms gave only negative results. The conclusions of 
Dr. Strauss were in entire conformity with those of 
Dr. Koch, but involved an additional and very import- 
ant statement — viz. that the shorter and the more vio- 
lent were the fatal attacks of cholera the fewer were the 
bacteria found in the intestine. It is evident that this 
fact is the very opposite of what should have been 
found had bacteria been essential in the causation of 
cholera. The more recent investigations conducted in 
Calcutta by Dr. Koch, which have already been cited, 
led him, however, to attribute to bacilli of a specific 
form the absolute origination of the disease. He poses 
the question in the following manner : Either these 
" comma bacilli " are a product of the cholera process, 



MORBID ANATOMY AND PATHOLOGY. 105 

or " the disease only arises when these specific organ- 
isms have found their way into the bowel," The former 
alternative he rejects, because, in his judgment, it as- 
sumes that the bodies in question must be pre-existent 
in every person who becomes affected with the disease 
— a hypothesis which he rejects, because they have 
never been found except in cholera. He therefore 
concludes that they are the cause of cholera. He 
points out that their first appearance coincides with 
the commencement of the disease, that they increase 
with it, and that they disappear with its decline. 1 The 
statement of Strauss quoted above does not, however, 
appear to harmonize with this conclusion, since the 
bacteria are said by him to have been fewest in the 
more violent and fatal attacks of the disease. Finally, 
the very positive conclusions of Drs. Klein and Gibbes 
are at such utter variance with the doctrine attributed 
to Dr. Koch that it seems no longer possible to accept 
the bacillar doctrine of the production of cholera. An- 
other of Dr. Koch's remarks is also open to criticism. 
After showing how rapidly the cholera bacteria multi- 
ply when kept moist, he states that they die after drying 
more quickly than almost any other form of bacteria. 
"As a rule, even after three hours' drying every vestige 
of life has disappeared." It is evident that this state- 
ment is not in harmony with the numerous facts, sev- 
eral of which have been cited, that cholera fomites 
have preserved their infectious qualities after several 
weeks. Dr. Koch endeavored to produce in animals, 
artificially, with these bacteria, a disease analogous to 
cholera, but without success ; and he adds, " If any 

1 Times and Gaz., March, 1884, p. 398. 



106 CHOLERA, 

species of animal whatever could take the cholera, it 
would surely have been observed in Bengal, but all 
inquiries directed to this point met with a negative 
result." Dr. Vincent Edwards, who, however, is of 
opinion that the cholera poison is " not an organism, 
but of the nature of a chemical compound of com- 
paratively unstable nature," reports that he produced 
fatal cholera in pigs by giving them the dejections of 
cholera patients. 1 But the Times and Gazette inclines 
to question that the pigs employed in Dr. Edwards' 
experiments were affected with true cholera. 



DIAGNOSIS. 

The most characteristic symptoms of Asiatic cholera 
have repeatedly been mentioned in the foregoing pages. 
They are rice-water evacuations by vomiting and purg- 
ing, rapid emaciation of the whole body, a cadaverous 
hollowness of the cheeks and eyes, a livid color of the 
face, hands, and feet, a feeble, thready, and at last ab- 
sent pulse, an icy coldness of the extremities, face, and 
even the breath, a loss of the elasticity of the skin, a 
thin and feeble voice, and intense thirst. But every 
one of these symptoms may occur in cholera morbus 
produced by a direct irritation of the stomach and 
bowels. It is rather their nature, we repeat, than their 
phenomena, that distinguishes these two affections 
from each other. In attempting to separate Asiatic 
cholera from other forms of cholera we must endeavor 
to dismiss from the mind the erroneous notion that 

1 Notes on the Poison contained in Choleraic Atomic Discharges. 



DIAGNOSIS. I07 

the term cholera denotes a definite disease identical 
in its cause, phenomena, and results. It is no more 
a disease than dropsy or fever is a disease. It is a 
complex group of symptoms which have in common 
the fact that they proceed directly from gastro- intes- 
tinal irritation, whose degree of severity — i. e. the 
presence or absence of certain grave symptoms — and, 
above all, its issue, depend chiefly upon the nature 
and intensity of the cause of the attack, and also, 
necessarily, upon the degree of resistance opposed to 
it by the subjects of the disease. Nothing has led to 
more error in regard to epidemic cholera than the 
ignorance of this pathological fact by some and the 
disregard of it by others. 

In the first portion of this article it was shown that 
the Greek, Roman, and Arabian conceptions of cholera 
morbus included a discharge of bile, the very symptom 
for the absence of which Asiatic cholera is notorious ; 
and also that the classical cholera, or cholera morbus, 
ended in recovery even more frequently than Asiatic 
cholera terminates in death. But local epidemics of 
cholera morbus sometimes take place which are of a 
severe and even of a grave type, and which also appear 
to originate in some peculiar atmospheric influence, for 
they prevail to a limited extent and in connection with 
vicissitudes of weather. Still more circumscribed epi- 
demics have been traced to unwholesome food and 
drink, and innumerable instances of individual attacks 
have been caused by irritants that are ranked as poisons 
and others which are reckoned as food or medicines. 
Now, under these various circumstances, which have in 
common gastro-intestinal irritation, there may be pro- 



108 CHOLERA. 

duced, if the irritation is excessive, a series of symp- 
toms closely resembling, if not identical with, those of 
Asiatic cholera. 

In illustration may be cited the comparatively famil- 
iar description of Sydenham. 1 These are his words : 
" There is vomiting to a great degree, and there are 
also foul, difficult, and straining motions from the 
bowels. There is intense pain in the belly, there is 
wind, and there are distension, heartburn, and thirst. 
The pulse is quick and frequent, at times small and 
unequal. The feeling of sickness is most distressing, 
and is accompanied with heat and disquiet. The 
perspiration sometimes amounts to absolute sweating. 
The legs and arms are cramped and the extremities 
cold. To these symptoms, and to others of a like 
stamp, we may add faintness." .... "As the summer 
came to a close the cholera morbus raged epidemically, 
and, being promoted by the unusual heat of the weather, 
it brought with it worse symptoms, in the way of 
cramps and spasms, than I had ever seen. Not only, 
as is generally the case, was the abdomen afflicted 
with horrible cramps, but the arms and legs, indeed 
the muscles in general, were afflicted also." .... At 
the risk of repetition an additional passage may be 
quoted from Sydenham's later definition of cholera 
morbus : " This is limited to the month of August or 
the first week or two of September. Violent vomiting, 
accompanied by the dejection of depraved humors, 
difficulty on passing them, vehement pain, inflation 
and distension of the bowels, heartburn, thirst, quick, 
frequent, small, and unequal pulse, heat and anx- 

1 Works, Sydenham Soc. ed., i. 163; ii. 8, 266. 



DIAGNOSIS. 



IO9 



iety, nausea, sweat, cramps of the legs and arms, 
faintings, and coldness of the extremities, constitute 
the true cholera — and it kills within twenty-four 
hours." 

In spite of the general likeness between this descrip- 
tion and the symptoms of Asiatic cholera, there are 
differences of considerable importance, which have 
been italicised in the quotations. These differences 
are such as may be attributed to the action of a harsh 
irritant in the case of cholera morbus, while in the 
epidemic (Asiatic) disease the distinctive phenomena 
are the result of a sudden and profuse intestinal flux. 
Macpherson, who had a long and extensive experience 
of epidemic cholera in India, after contrasting in detail 
its phenomena with those of cholera nostras, sums up 
the discussion in these words : " Cholera indica is 
essentially a very fatal disease, while cholera nostras 
is usually a mild affection and is seldom fatal, although 
it was called atrocissimns et peracntus, and has undoubt- 
edly killed in from eight to twenty-four hours." * In 
regard to the individual symptoms this very compe- 
tent reporter does not recognize a single one as being 
absolutely peculiar to either disease. Even the ancients 
already referred to, after describing bilious evacuations 
as being characteristic of cholera nostras, add that 
sometimes also they are whitish ; and modern writers, 
both before and since the advent of Asiatic cholera in 
Europe, have made a similar observation. Thus, 
Quinquaud, in his description of cholera nostras, of 
which a slight epidemic occurred in 1869 at the Hos- 
pital St. Antoine in Paris, says : " The principal symp- 

1 Times and Gaz., Dec, 1870, p. 725. 
10 



I IO CHOLERA. 

toms were vomiting and purging, sometimes of a bilious 
and sometimes of a rice-water liquid ; a shrivelled and 
cyanotic skin, the latter appearance being sometimes 
strongly marked ; anxiety, coldness, cramps, altered 
voice, and suppression of urine. 1 In 1875 thirty -three 
cases of this disease occurred at Valenciennes, near 
Paris, and its symptoms were thus summarized by 
Manouvriez: 2 "Repeated vomiting, first of food, and 
then of a dark-green liquid ; diarrhoea, which was at 
first fecal and then bilious, but afterward serous and 
like rice-water ; painful tension of the epigastrium and 
tenderness of this part; headache, cramps in the legs, 
suppression of urine ; pallor, coldness, and dryness of 
the skin, especially of the limbs ; pinched features, a 
blue circle around the eyes, a small and scarcely per- 
ceptible pulse, and a faltering and whispering voice." 
Yet of the thirty-three cases only two were fatal — the 
one a child of four years and the other an infant of as 
many months. The substantial identity of nature of 
these two local epidemics, and the almost equally 
close relation of their symptoms to those of epidemic 
cholera, must be quite apparent. 

Yet the contrasts are neither slight nor unimportant; 
and the most striking and significant is the trifling 
mortality of the European as compared with the 
Asiatic disease, notwithstanding the grave symptoms 
present in the former. It may be regarded as certain, 
we think, that the reason of this difference of danger 
lies in a corresponding difference in the nature of the 
causes of the two forms of disease. The rapid recovery 
from cholera morbus produced by changes of weather, 

1 Archives gen, Mars, 1870, p. 308. 2 Ibid., Sept., 1877, p. 298. 



DIAGNOSIS. HI 

acid fruits, and indigestion renders it certain that no 
material lesion of the gastro-intestinal mucous mem- 
brane has been produced ; while, on the other hand, 
inspection after death from epidemic cholera or by 
corrosive poisoning renders it equally certain that the 
damage to that membrane is substantial and wide- 
spread, as well as often irreparable, and that, there- 
fore, " the powers of life that resist death" must be 
engaged in a very unequal and often fruitless struggle. 
The cramps in cholera nostras are, as a rule, less 
severe than in epidemic cholera, while the colicky, 
and in general the abdominal, pains are greater in 
the former than in the latter disease. The reason of 
this difference appears to be that muscular spasm is 
the natural result of depletion, whether sanguine or 
serous, while colic is an effect of irritation of the sur- 
face of the mucous coat of the bowel, and not of its 
destruction, such as occurs in epidemic cholera. 

It is true only in a limited degree, and indeed only 
upon a superficial survey of the symptoms, that the 
effects of irritant poisoning are like those produced by 
Asiatic cholera. The analogy between the two was 
pointed out, among others, by Sedgwick in 1867. 1 
The resemblance appeared so striking to the vulgar 
eye that in Paris, and perhaps elsewhere, a popular 
tumult followed the first violent outbreak of epidemic 
cholera, and it was charged that the wells had been 
poisoned. The cases that most resemble cholera are 
the following : "Acute poisoning by corrosive subli- 
mate, by arsenic, and by mineral acids, especially 
j nitric acid; the effects which follow the eating or 

1 Med.-Chir Trans., li. I. 



1 1 2 CHOLERA. 

drinking of poisonous animal matters, such as taint- 
ed or simply unwholesome meat or fish, and milk 
which has undergone some injurious but yet un- 
known change, decomposing vegetables, and some of 
the poisonous fungi, and the excessive action of cer- 
tain drugs, for the most part belonging to the class of 
drastic purgatives," as elaterium and croton oil. The 
effects produced by these agents constitute a cholera 
morbus, and therefore resemble cholera, and have been 
occasionally, and almost unavoidably, mistaken for it. 
It is remarkable that suppression of urine may occur 
among them, as well as vomiting, purging, and col- 
lapse. As Griesinger and others have pointed out, 
the order in which the symptoms occur is a valuable, 
and generally an available, ground of diagnosis. In 
cholera, diarrhoea always occurs before vomiting, while 
in the various irritant poisonings mentioned vomiting 
precedes diarrhoea. In irritant poisoning also there is 
generally severe abdominal pain — not so much colicky 
and paroxysmal as constant and burning; the stools 
are not so copious as in cholera, and they do not 
possess the rice-water aspect, but are rather dark, 
bloody, and fetid, and are voided with tenesmus or 
with heat in the anus ; and even when the urine is 
suppressed it is less persistently and completely so than 
in cholera, and attempts to void it are attended with ves- 
ical tenesmus and strangury. In a doubtful case it is 
important to ascertain whether a metallic or other 
unpleasant taste is perceived in the mouth, whether this 
cavity or the throat bears marks of corrosion, whether 
any unusual article of food has been used, etc. More- 
over, it is of extreme importance to learn whether 



PROGNOSIS. II3 

Asiatic cholera prevails, not merely in the immediate 
neighborhood, but at any place from which diseased 
persons or infected goods may have arrived. The 
instances should not be forgotten in which cholera- 
infected clothing from Europe has developed the dis- 
ease in the valley of the Mississippi. Nor should 
those still more numerous cases be overlooked in 
which travellers affected with choleraic diarrhcea have 
disseminated the disease at great distances from their 
starting-point, although unconscious of the nature of 
their own ailment, whose seed they were sowing along 
their route. 



PROGNOSIS. 

Like the diseases called septic, of which the erup- 
tive fevers may be taken as examples, and also like the 
effects of irritant poisons, the gravity of cholera must 
mainly depend upon the amount and the activity of 
the specific poison that is received into the system. 
It is most probable that the cholera-poison is organic, 
and that it has a limited power of reproduction and 
term of existence, a period also of intense activity and 
a period of exhaustion ; in a word, that either by pro- 
gressive dilution as an inorganic substance or by or- 
ganic senescence it finally ceases to exist. By no 
other theory is it possible to explain the numerous 
degrees of severity which cholera exhibits, from a mild 
indisposition to a malignant and rapidly fatal disease. 
On the one hand, the patients, if they may so be 



1 14 CHOLERA. 

called, are hardly prevented from attending to their 
customary occupations. They may even be able to 
travel and carry the disease to distant places, and so 
appear to justify the erroneous and irrational doctrine 
of the atmospheric or spontaneous origin of cholera. 
On the other hand, the entire apparent duration of an 
attack may not exceed two or three hours, during 
which all the distinctive symptoms of the disease may 
be crowded together in the most appalling forms. 
Such grave cases are always most numerous at the 
commencement of an epidemic. These statements are 
true not only in regard to individual cases in the 
greater number of epidemics, but they represent the 
distinctive character of particular epidemics, some of 
which are as remarkable for their benignity as others 
are for their extreme malignity. For such contrasts 
no plausible reason can be suggested, unless it be a 
difference either in the essential virulence of the mor- 
bid poison or in the dose of it imbibed. That they 
are due to the activity rather than to the quantity of 
the poison seems to be proved by the progressive 
weakening in the gravity of the cases ; for if the quan- 
tity of the poison remained the same some malignant 
cases might be expected to occur even during the de- 
cline of an epidemic. 

These considerations help to explain the extreme 
diversities of mortality in different epidemics. The 
extremes may be stated at 10 and 90 per cent., and 
they would perhaps be still wider apart if all the mild 
cases, which are never reported — many of which, in- 
deed, do not even fall under medical observation — 
were included in the reckoning. The general or aver- 



PROGNOSIS. 115 

age mortality of cholera is about 50 per cent. Ac- 
cording to Albu, the epidemics in Berlin from 1 83 1 to 
1873 gave a total of 28,753 cases and 18,916 deaths; 
that is, a mortality of 65.8 per cent. (Eichhorst). It 
should be noted that, as in other epidemic diseases, 
there is no uniform proportion between the extent and 
the mortality of cholera epidemics. Some of very 
limited extent have been proportionally the most de- 
structive. It should also be remembered that the dis- 
ease is far more fatal in infancy and old age than at any 
other period of life, and for a similar reason it is very 
dangerous to all who are weakened by any cause, such 
as an inherited morbid diathesis, a chronic debilitating 
disease, etc. There seems to be a doubt whether its 
male or female victims are the more numerous. In 
this connection it may be suggested that while males 
are more likely to contract the disease by drinking 
contaminated water, etc., more women are exposed to 
its contagion by their intimate relations with the sick, 
by their handling and washing infected fomites, by 
carrying away the cholera discharges, etc. 

Undoubtedly, the class of society to which cholera 
patients belong is not without influence on its progno- 
sis. Not only is the total mortality greater among 
the laboring classes, but the individual belonging to 
those classes has a less chance of recovery, because he 
is not apt to resort to treatment on the appearance of 
the premonitory signs of the disease, and because the 
treatment he receives is less intelligently and sedulous- 
ly pursued by his physicians and friends. 

In regard to the particular symptoms which are 
favorable or unfavorable, nothing need be added to 



Il6 CHOLERA. 

what has already been stated in detail, unless it be that 
during the height of the attack the danger is to be 
measured by the degree of prostration and of the stasis 
of the blood, and, during reaction, by the grade of the 
typhoid state. Gradual reaction, as denoted by the 
state of the skin and the pulse and a more natural as- 
pect of the stools, is generally indicative of improve- 
ment. 

Finally, a word of caution may be given to those 
who are apt to attribute all the favorable changes in 
the conditions of an epidemic to the sanitary or medi- 
cinal measures they have instituted, Cholera epidem- 
ics are remarkable for the comparatively short period 
of their duration, which may be stated at less than a 
month in the same place. Doubtless, judicious sani- 
tation and timely treatment save a great many lives, 
but the qualifying fact, already insisted upon, must not 
be overlooked, that the mortality occasioned by the 
disease in a given place is greatest during the first 
period of its prevalence, and that thenceforth it gradu- 
ally declines. Yet it is of essential significance that 
the disease rarely attacks a large number of persons 
simultaneously ; the epidemic proper is usually pre- 
ceded by a few scattering cases which are apt to be- 
come foci of ignition that presently unite to form a 
widespread conflagration. The recognition of these 
cases, their isolation, and the proper treatment of the 
localities where they occurred have frequently stamped 
out what might have been the commencement of a 
deadly epidemic. 



PRE VENTION. 1 1 7 

PREVENTION. 

The history of cholera demonstrates conclusively 
that since the disease, outside of India, never arises 
spontaneously, it must be more or less preventible, 
partly by excluding its seeds and partly by rendering 
the soil in which they are planted more or less unfit 
for their development ; in other words, by the detention 
of suspected persons and fomites, and sanitary cordons 
and by various measures of local sanitation. 

In regard to the former there would be compara- 
tively little difference of opinion, at least theoretically, 
if both measures were alike efficacious. But there 
would seem to have prevailed a tendency in official 
quarters to undervalue the efficiency of both. Those 
who made and administered the sanitary laws relating 
to cholera seem to have forgotten the emphatic ques- 
tion, " What will not a man give for his life ?" or at 
least to have considered that whatever value some 
men may set upon their own lives, the lives of other 
men become of no account when balanced against the 
needs, or even the conveniences, of commerce. The 
ethics which justified the introduction of opium into 
China by the English and the American gift of alcohol 
to the Indian to gratify a lust for lucre or for land is 
only paralleled by those contained in the official pro- 
tests against cholera quarantines. At the International 
Medical Congress held in 1873 at Constantinople it 
was almost unanimously resolved that " the practice 
of (land) quarantine as now carried out ought not to 
be maintained, because, on the one hand, it does not 
constitute a real protection, and, on the other hand, it 



Il8 CHOLERA. 

is directly opposed to the interests of commerce and indus- 
try!' A leading critic, in commenting upon this, re- 
marks that if a quarantine were possible it would give 
no real security, because it would be evaded, just as 
customs laws are evaded by smuggling. 1 A logical 
deduction from this curious argument would be that 
customs laws should be abrogated. In 1880 was pub- 
lished the report of the German Imperial Commission 
on the cholera epidemic of 1873 in Germany, edited 
by Hirsch, from which we learn that " all the German 
medical experts agree in condemning the employment 
of quarantine, for, while largely detrimental to the in- 
terests, welfare, convenience, and happiness of a com- 
munity, it is quite inert and inefficient as a safeguard 
against the further diffusion of cholera." 2 Whether 
this opinion refers only to land quarantine or not is 
left in doubt, but the spirit of subordinating the lives 
of the people to the commercial interests of a country 
is just the same as, and is not less worthy of condem- 
nation than, the spirit which has more than once blind- 
ed customs officials to the disease on board of vessels 
from which it has afterward issued to destroy thou- 
sands of lives. 

One of the most remarkable papers ever issued by 
the government of a civilized nation was that in which 
the British Foreign Office declared in 1882 that "the 
government of H. M. has no hesitation in declaring 
that no outbreak of cholera in Egypt, or even in 
Europe, can be regarded as due to an importation of 
the disease upon a vessel from India." The Sanitary 
Council, sitting at Constantinople, on the contrary, 

1 Practitioner, xii. 226. 2 Ibid., xxvi. 159. 



PRE VENTION. 1 1 9 

affirmed that " cholera propagates itself in the absence 
of quarantine measures or when these are inefficient ; 
as, for example, in Egypt in 1865 and at Mecca in 
1882, during the last pilgrimage. On the other hand, 
the success of quarantine is complete when it is rigor- 
ously applied, as it was in Mesopotamia in 1879 and at 
El Wedj and Thor in 1881. . . . What is absolutely 
undisputed is the fact that when cholera exists in the 
countries which send out pilgrims, these latter bring 
it into the Hedjaz. To prevent its introduction in such 
manner by wise regulations strictly enforced, without 
at the same time touching the general interests of 
commerce, is the duty and the aim which the Interna- 
tional Council of Health and the administration have 
at heart." l Later, in the same year, Fauvel, in a 
communication to the French Academy of Sciences, 
confirmed his earlier statements regarding the effica- 
ciousness of the quarantine at Suez, saying that the 
Indian contingent of the English army in Egypt was 
entirely preserved from the disease, and the pilgrim- 
ships from Bombay having been subjected to quaran- 
tine, the epidemic, although a violent one, completely 
exhausted itself. 2 

It seems to be overlooked that in national as well as 
in personal affairs " honesty is the best policy," and 
that if, instead of concealment or false statements re- 
garding the sanitary state of ships, their passengers, 
and cargoes, and equally false assertions respecting the 
contagiousness of cholera, and a contemptuous neglect 
of well-tried preventive measures, — if, instead of this 

1 Amer. Jour, of Med. Sci., April, 1883, p. 544. 

2 Archives gen., August, 1883, p. 235. 



120 CHOLERA, 

delusive and disastrous policy, all nations had honestly- 
carried out the rules prescribed by experience for the 
exclusion of the disease, and for its management after 
it had passed the frontiers of a country, there can be 
little doubt that its ravages would ere this have been 
confined to the region in which it originated. As we 
have seen, there is urged against the enforcement of a 
rigid quarantine by land or sea the singular argument 
that it has not always excluded the disease. A more 
logical inference would seem to be that since it suc- 
ceeded, not completely, but yet partially, its ineffi- 
ciency should be charged to its imperfect execution ; 
or, even granting that the absolute exclusion of chol- 
era is impracticable in every instance, including cases 
of choleraic diarrhoea, contaminated clothing and mer- 
chandise, does it therefore follow that the transit of 
men and things should be unimpeded ? As well 
might it be maintained that because one or more 
houses cannot escape destruction by fire, therefore no 
effort should be made to save the remainder of a 
threatened city ; as well might it be argued that be- 
cause some men must be killed in battle, no precau- 
tions should therefore be used to preserve the rest of 
the army ; as well abstain from all local sanitation in- 
tended to mitigate the ravages of the disease, because, 
do what we may, some victims it will surely have. 
This is taking counsel from despair ; is a stupid fatal- 
ism which one might imagine to have been imported 
with the disease from the East ; or it may be a sign of 
the unconscious blindness of Mammon-worshippers, 
who, neither fearing God nor regarding man, have as 
little pity for the victims of cholera, permitted, if not 






PRE VENTION. 1 2 1 

invited, by them to scourge the nations, as devout 
Christians once felt for the negroes who were bought 
or kidnapped in Africa to toil and die under the lash 
of the slave-driver. 

Probably no sanitary cordon nor any " quarantine " 
will invariably and completely exclude cholera, since 
it is transmissible by living men and by water and by 
fomites of various descriptions, and, worst of all, by 
men who neither exhibit its characteristic symptoms 
nor are conscious of the poison which they conceal 
and disseminate. But, as has already been urged, it is 
no argument against preventive measures that they 
are not absolutely perfect in their efficiency. If they 
sometimes succeed in arresting the progress of chol- 
era, and if they always, when honestly executed, les- 
sen the number of channels through which the infec- 
tion can be conveyed, and thereby reduce to a mini- 
mum its fatal effects, they ought to be maintained and 
perfected, and not decried or abolished. It is difficult 
to characterize that state of mind which concludes 
against the use of a salutary measure because its effi- 
ciency is not absolute, the more so when it is admitted 
that its inefficiency is not intrinsic, but due to negli- 
gent, and even fraudulent, administration. The pre- 
ponderance of official and personal authority is alto- 
gether on the side of the necessity of a quarantine, not 
in its literal, but in its technical, sense. The Interna- 
tional Medical Congress of 1 874 declared as follows : 
" Quarantine ought to be limited to the time requisite 
for the examination and disinfection of the ship, the 
crew, and the passengers ; and if there be no disease 
on board the latter should be released immediately 



122 CHOLERA. 

after disinfection. But if there be cholera or sickness 
of a doubtful nature on board, it will be necessary to 
isolate and disinfect the ship also." The same con- 
gress, however, wholly condemned land quarantines, 
apparently upon the sole ground of the extreme diffi- 
culty of rendering them efficient — an argument, as be- 
fore remarked, that touches not the principle of the 
measure, but only the manner of its execution. In 
this respect the congress occupied a lower position 
than its predecessor of 1866, which held that the futil- 
ity of quarantine in " arresting the march of cholera " 
arose " rather from the unintelligent application of the 
measure than from any fallacy in its principle." * 

It would burden this narrative even to enumerate 
the instances in which a strict quarantine has protected 
places to which cholera has been carried by sea. In 
the United States numerous examples might be given 
of seaports into which cholera was brought from for- 
eign countries, and within whose quarantine-stations it 
was confined by rigid sanitary regulations ; but it is 
sufficient to cite the case of New York, through whose 
quarantine at Staten Island nine-tenths of all emigrants 
to America have passed. Writing in 1867, Dr. Peters 
said : " There have been fourteen epidemics of cholera 
at Staten Island, and only four have reached New 
York." A large number of illustrations has been 
collected by Dr. Smart, Inspector-General, R. N., 2 
who sums up the matter as follows : " Believing that 

1 Practitioner, xxviii. 393. 

2 Lancet, April, 1873, pp. 555, 659; Times and Gazette, April, 1874, 
p. 387. Compare also Colin, Brit, and For. Med.-Chir. Rev., July, 
1874, pp. 42-44. 



PRE VENTION. 1 2 3 

cholera has frequently been excluded from islands by 
quarantine, and as often introduced by its non-observ- 
ance, I regard it as a truly preventive measure ; but, 
recognizing the impracticability of exacting it under 
many circumstances, I would insist on the most strict 
isolation of all the first cases or units of disease, 
whether introduced from without or originating from 
relationship to introduced cases or persons or goods 
imported from infected countries." 

While experience demonstrates the efficacy, and 
therefore the necessity, of quarantine against cholera 
in seaports, it has also shown that the same agent of 
prevention need not be invariably and rigidly applied. 
When quarantine meant literally a detention, and 
almost an incarceration, for forty days, it often failed 
through its very rigor at a time when proper meth- 
ods of disinfecting ships, cargoes, crews, and passengers 
were either unknown or inefficiently applied. It is 
now certain that quarantine may be reduced to a frac- 
tion of its original duration, and yet possess a much 
greater degree of efficiency, its length depending upon 
the number and the sanitary condition of the crew, 
etc., the nature of the cargo, etc. It is evident that a 
ship carrying only cabin passengers is less open to 
suspicion than one crowded with filthy emigrants, 
although both may have sailed from the same chol- 
era-infected port. A more liberal rule may govern 
the one than the other; and in the second case a 
rigid inspection and cleansing of luggage may be 
imperative which would be superfluous as well as 
vexatious in the first case. The importance of such 
a treatment of emigrants' effects has already been 



1 24 CHOLERA. 

illustrated by cases in which they caused an out- 
break of cholera after having been carried from a 
seaport into an interior town many hundreds of miles 
distant. 

In regard to the time during which a vessel that has 
had cholera on board within a week or ten days should 
be detained under sanitary inspection and treatment, 
including a thorough cleansing of the passengers and 
their effects, no absolute rule can be laid down ; but it 
would appear that if no suspicious cases arise within a 
week, there need be little apprehension that any will 
occur. 

The sanitary measures which should be undertaken 
wherever there is reason to fear an invasion of cholera 
are, in the first place, such as are equally appropriate 
in anticipation of any infectious and contagious epi- 
demic disease, and relate especially to the removal of 
all sources of putrid emanations, whether in stagnant 
ponds, in streets, markets, shambles, sewers, privies, 
cellars, or inhabited rooms ; for these influences, 
although they do not cause cholera, yet, by lower- 
ing the vitality of persons exposed to them, create an 
abnormal susceptibility to disease. Many instances 
in Europe might be cited to prove that whole cities, 
which in the earlier epidemics were devastated by 
cholera, were either spared entirely in the later ones 
or suffered in a far less degree. The measures which 
proved most efficient were an improved water-supply 
and a better system of sewerage ; and this fact strongly 
corroborates the belief that contaminated water and 
fecal products are the principal agents in propagating 
this disease. In 1866 the good effects of domestic 



PRE VENTION. 1 2 5 

cleanliness were exhibited in New York. The late 
Elisha Harris in his report as registrar of vital statistics 
said : " In houses and localities where well-marked 
first cases were not promptly treated by local cleansing 
and specific disinfection cholera soon gained a foothold 
as a local epidemic, and we have found no large group 
of fatal cases in which this was not true ; while in a 
great number of instances where the disinfection was 
prompt and adequate the arrest of cholera in the very 
worst localities and the worst houses and population 
was immediate and final." 

" In three hundred and sixty-two houses where in- 
dividuals or families were smitten with cholera, but 
which were promptly brought under full sanitary puri- 
fication, the pestilence did not extend beyond the fam- 
ily in which the first case occurred." Cleanliness is 
the best disinfectant, but during epidemics of cholera, 
as of other diseases, the popular faith is very strong in 
numerous articles called by that name. The real value 
of these preparations is commercial rather than sani- 
tary, but, indirectly, they are useful by prompting those 
who use them to be more diligent in searching out and 
removing many sources of air-contamination that per- 
haps invite and intensify attacks of cholera. 

The disinfectants in common use comprise chlorine 
gas, chlorinated soda, chloride of zinc, sulphate of iron, 
corrosive sublimate, permanganate of potassium, car- 
bolic acid, and the fumes of burning sulphur. Some of 
them — and especially the chloride of zinc, sulphate of 
iron, permanganate of potassium, and carbolic acid — 
are supposed to be capable of destroying the infectious 
principle of the vomit and stools. Another method 
11* 



126 CHOLERA. 

is to receive such matters in vessels containing saw- 
dust, which, after being dried, is consumed by fire ; 
and still another is to mix them with dry earth and 
bury them. If they are thrown into water-closets or 
privies, they should have added to them a portion of 
sulphate of iron. Whatever has been used by cholera 
patients should be destroyed, unless of value, and in 
that case it should be thoroughly purified by hot air 
or boiling water and long exposure to the sun. The 
importance of having large and well-ventilated rooms 
for cholera patients is very great, but less, perhaps, 
for the patients themselves than for their medical 
attendants and nurses. All persons should be ex- 
cluded from them who are not required by the duties 
of the sick chamber, and in case of death funeral 
assemblages ought not to be allowed ; nor, during a 
cholera epidemic, ought crowded assemblies for any 
purpose to be permitted. 

The following rules were drawn up by Drs. Koch, 
Skrzeczka, and Von Pettenkofer, the commission of 
experts appointed by the Prussian board of health : 

" Cholera is propagated by intercourse between peo- 
ple, and the infectious material clings, without excep- 
tion, to men and the articles with which they come in 
immediate contact. The spread of the disease will be 
very greatly promoted, as experience has often shown, 
if, on its appearance in large places, the inhabitants 
take to flight and spread the germ of the disease far 
and near. This especially dangerous exodus of the 
population must be severely prohibited. Instead of 
thus leaving the infected place, it is easier to protect 
one's self from cholera by a proper mode of living and 



PRE VENTION. 1 2 7 

by observing the following precautionary measures, 
which cannot be done so well while travelling or away 
from home : 

" Every one who would not endanger himself by re- 
ceiving the germ of the disease into his house should 
keep away from them those who come from stricken 
places. As soon as the first case of cholera appears in 
a place the persons coming from that place must be 
considered as in all probability bringing the disease- 
germ with them. 

" In time of cholera one should lead as regular a 
life as possible. Experience has shown that all trou- 
bles of digestion especially favor cholera. One should, 
therefore, particularly avoid whatever may cause di- 
gestive troubles, as excesses in eating and drinking, 
and the use of food not easily digested. 

" Everything which causes diarrhoea should be 
avoided. As soon as symptoms of diarrhoea appear 
a physician should be sent for. 

" No food should be used which comes from a house 
in which cholera rages. Food the origin of which is 
uncertain should only be used after being cooked. The 
use of uncooked milk is to be especially avoided. 

" All water which is fouled by human waste is to be 
strictly avoided. Water which comes from surface- 
wells in inhabited places is to be regarded with suspi- 
cion, as is also water from swamps, tanks, streams, and 
small rivers. Water is especially to be regarded as 
dangerous which has been in any way contaminated by 
cholera dejecta. It should be particularly observed, 
also, that water which is used for cleaning vessels and 
soiled clothes is not thrown into wells and watercourses 



128 CHOLERA. 

or in their vicinity. Since it is impossible to recognize 
contaminated water, only water which has been previ- 
ously boiled should be used. These remarks are to 
be applied not only to water for drinking purposes, but 
to that which is used about the house for any purpose, 
since the infecting principle may be conveyed from the 
human body to the water used in the kitchen for wash- 
ing and cooking food and for laundry purposes. 

" People are especially warned against the opinion 
that the drinking-water alone can act as the bearer of 
the infecting material, and that one may think himself 
completely guarded if unsuspicious or boiled water 
alone be used. 

" Every cholera patient may be considered a disease- 
centre, and it is therefore advisable that the patient 
should not be cared for at home, but should be carried 
to a hospital. If this is not practicable, all unnecessary 
intercourse with the patient should be strictly avoided. 

" No one should visit a house in which there is 
cholera unless his duty calls him there, nor such houses 
as were visited by the disease in former epidemics of 
cholera. Nor should one go to places, in time of chol- 
era, in which large numbers of people are gathered 
(yearly at fairs, places of amusement, etc.). 

" No food or drink should be taken in rooms in 
which there are cholera patients. Clothes or linen 
soiled by discharges of cholera patients should be 
burned or boiled immediately or placed in a 5 per cent, 
solution of carbolic acid for twenty-four hours. The 
discharges from cholera patients must as soon as possi- 
ble be placed in vessels which contain a 5 per cent, so- 
lution of carbolic acid, and the vessels should be washed 



PREVENTION. 1 29 

out with this solution when emptied. The discharges 
mixed with this solution may be thrown into necessa- 
ries or water-closets, but care must be taken that the 
discharges are not thrown into wells or into streams 
the water of which is used. 

" The floors and all articles soiled by cholera dis- 
charges must be cleaned with dry cloths or rags, which 
must then be burned or placed in a 5 per cent, solution 
of carbolic acid. Everything which comes in contact 
with the patient which cannot be destroyed or disin- 
fected by boiling or in the carbolic solution, must be 
rendered harmless by means of hot steam in a special 
place of disinfection, or kept at least six days unused 
in a dry, airy place. The rooms in which there are 
cholera patients must, whenever possible, remain unin- 
habited for six days, and should be aired day and night 
during this time, so that they may be completely dried ; 
and they should finally be dried by artificial heat. 
Those who come in contact with the patient or with 
the beds and clothing should thoroughly wash their 
hands with soap and water, and afterward, when pos- 
sible, wash them with a 5 per cent, solution of carbolic 
acid. This is especially necessary when they are soiled 
with the discharges from the patient. People are ex- 
pressly warned against eating when the hands are un- 
clean. 

" When death occurs, the body, whenever possible, 
should be removed from the house and carried to a 
dead-house. If the washing of the body cannot be 
performed in the dead-house, it should be omitted. 
The burial should be conducted in the simplest man- 
ner possible. There should be no attendance at the 



1 30 CHOLERA. 

house of death, and people should not attend the 
funeral. 

" The clothing, linen, and other articles used by the 
patient or for the body should not be sent away before 
being certainly disinfected. It is strongly advised that 
when such articles are received they be sent immedi-' 
ately to be disinfected. Laundries should only receive 
from cholera cases linen which has been previously 
disinfected. 

" Other precautionary measures than those here given 
against cholera are unreliable, and all persons are 
warned against the use of so-called preventive medi- 
cines in time of cholera." x 

During epidemics of cholera, as of some other dis- 
eases, the liability to be attacked is greatest when the 
vital powers are depressed by mental or by physical 
causes. Hence it is desirable that one's courage and 
confidence should repose upon a consciousness of 
having done whatever is recognized as proper to ward 
off the disease — not by a minute, watchful, and anxious 
attention to rules at every step, but by such a general 
care of the health as good sense and experience en- 
join. Undoubtedly, other things being equal, the 
weak, sickly, careless, and imprudent are more liable 
to suffer than the strong and cautious, and therefore it 
is incumbent upon all to maintain as high a degree 
of health as possible, avoiding not only all probable 
sources of contagion, direct or indirect, but excessive 
fatigue, catching cold, depressing emotions, sexual 
excesses, etc. During the first cholera epidemics in 
this country it was considered so dangerous to eat fruit 

1 Deutsche Med. Wochensch., August 7, 1884, 



TREATMENT. 131 

and fresh vegetables that many persons lived entirely 
upon meat, rice, and bread. Such a regimen intensi- 
fied choleraphobia, and was also an unsuitable mid- 
summer diet. There is no reason to believe that any 
intrinsically wholesome food need be prohibited during 
the prevalence of cholera. 

The one article of diet about which the greatest and 
most peculiar care should be taken is water. It is the 
first duty of towns supplied with water from a common 
source to be sure that it is, and continues to be, uncon- 
taminated. Well-water should be used as little as pos- 
sible after the disease has made its appearance, and, as 
an additional precaution, no water should be drunken 
that has not previously been boiled. Where ice can 
be procured it may be used to restore the boiled water 
to an agreeable temperature for drinking. Filtered 
water, provided that it be properly filtered, may like- 
wise be regarded as innocuous. 



TREATMENT. 

If regard be had to the various methods and particu- 
lar medicines which have been used in the treatment 
of cholera, it will appear that in hardly any other acute 
disease has a greater number or variety been employed. 
If, on the other hand, we endeavor to learn what meas- 
ures have been really and generally curative in cholera, 
and what are they to which, on the occurrence of an 
epidemic of the disease, we may turn with confidence 
in their power to cure, the result of the investigation 
is disheartening, and adds to the accumulated proofs 



132 CHOLERA. 

that the power of medical art is exceedingly restricted. 
To this conclusion we must assent at whatever cost to 
a faith which is strong in proportion to the ignorance 
out of which it grows. The discovery of microbes in 
the discharges of cholera patients, and the conclusion 
reached at once, per saltum, that the remedy for the 
disease must be looked for among the agents fitted to 
destroy these microscopical organisms, have led to the 
use in its treatment of a variety of agents described 
elsewhere. But scientific enthusiasts are not always 
very close reasoners, and in this instance they over- 
looked a consideration which they had been reminded 
of by critics as competent in such a matter as Drs. T. 
Lauder Brunton and P. H. Pye-Smith, who say : " If 
cholera be caused by microbes, we must seek to de- 
stroy them in order to prevent the spread of the disease. 
The cure of an individual patient is, however, a very 
different thing, for the symptoms from which he suffers, 
and which are likely to bring about a fatal termination, 
are in all probability not due to the microbes them- 
selves, but to the chemical poisoning which they have 
generated. If we could destroy the yeast-plant com- 
pletely, we might entirely prevent the formation of al- 
cohol, and thus put a stop to drunkenness, but meas- 
ures calculated to destroy the plant would be of no use 
whatever for the purpose of restoring consciousness to 
a man who was dead drunk or for treating a case of 
delirium tremens. Unfortunately, we do not as yet 
know the proper means for treating a case of cholera." 1 
To attempt it by the administration of the agents most 
capable of destroying them would be to illustrate 

1 Practitioner, xxxiii. 356, 



TREA TMENT. 1 3 3 

anew, and even exceed, the ancient fable in which the 
bear while killing the fly upon his master's face crushed 
its features to a jelly. In like manner, Semmola of 
Naples maintains that the parasiticide treatment of 
cholera can never arrest the disease, because the effi- 
cient agents cannot be used in such quantities as will 
destroy the microbes without injuring the patients, and 
because the death of the microbes would form only a 
portion of the treatment, and the least important part, 
since (in his opinion) " the gravest symptoms of cholera 
are incontestably caused by a chemical principle (pto- 
maine) which poisons successively the nervous centres, 
and is already in process of formation in the bowel 
when the diarrhoea announces the beginning of the 
attack." 1 The first proposition of this writer is as prob- 
able as the second is unfounded. 

The claims of anti-bacterial agents to cure cholera 
have been quaintly but efficiently disposed of by Dr. 
Peters: 2 "In 1872, Dr. Netwetsky found bacteria, 
which he did not distinguish from common bacteria, in 
large quantities in rice-water discharges, and set about 
to kill them all in a rudely scientific but exceedingly 
practical way. He always used two drachms of rice- 
water discharge in all his experiments, and found that 
one drachm of laudanum did not kill bacteria in this 
small quantity, nor one drachm of tincture of nux 
vomica ; neither did alcohol kill them ; nor ten grains 
of quinine ; nor thirty grammes of camphor ; nor five 
or even ten drops of strong so-called carbolic acid, 
which is not an acid, but an alcohol ; nor one drachm 

1 Bulletin de therapy cvii. 481. 

2 Med. Record, xxvii. 204. 
12 



1 34 CHOLERA. 

of tar ; nor ten grams of calomel, between the parti- 
cles of which the bacteria not only lived and moved, 
but on the fifth and sixth days new granular masses 
and new crops of bacteria had formed. The same had 
happened with camphor. One drachm of a strong solu- 
tion of chloral did not kill bacteria, and it required one 
drachm of chloroform and a saturated solution of sul- 
phate of iron. If there is any truth in science or sound* 
reasoning, all these favorite remedies may be useful in 
other diarrhoeas and in cholera morbus, but cannot be 
reliable in true specific choleraic diarrhoea, and we 
know they all fail in fully-developed cholera." 

If we consider the matter rationally, we ought not to 
be surprised or humiliated on account of the compara- 
tive helplessness of medicine in this disease, since, if 
we reflect upon it, the case is by no means peculiar or 
exceptional. Every disease that may become mortal 
occurs more or less frequently with phenomena which 
place it beyond the resources of therapeutics as com- 
pletely as cholera is in its most malignant forms ; and 
yet no one lays it to the charge of medicine that the 
various fevers, for example, are at times utterly unin- 
fluenced by the most rational and judicious treatment. 
Nor does any one bring a railing accusation against 
medicine when accident fatally damages a part essential 
to life. 

One accident of frequent occurrence presents a cer- 
tain analogy to cholera in its effects, and that is a burn 
or scald involving a very large portion of the skin. In 
cases of this sort experience assures us that death is 
almost inevitable, and that the duty of the physician 
is to avoid officious and meddlesome treatment, and 



TREATMENT. 1 35 

address himself to soothe the patient's suffering and 
maintain his strength, if haply the powers of nature 
may triumph over the effects of the injury. This, 
too, is the lesson, substantially, which experience has 
taught respecting cholera. It is certain that in this 
disease the function of the whole gastro-intestinal 
mucous membrane is reversed, and that it is no longer 
a secreting and absorbing organ, but one almost ex- 
clusively exhaling, and that through it the liquid 
which is essential to carrying on the functions is 
rapidly running away. If the lesion on which this 
symptom depends is complete, if the gastro-intestinal 
mucous membrane has entirely lost its natural func- 
tion, evidently it is quite futile to address any treat- 
ment to this organ. But if, as probably happens in a 
great majority of the cases, the disorganization takes 
place gradually, it is evident that there is more to hope 
from remedies when the disease is gradually developed 
^^than when it reaches its acme at a single bound and 
leaves no time for medical intervention. The one un- 
mistakable lesson that experience teaches respecting 
the treatment of cholera is, that its success depends 
upon its prompt and early application. Almost as 
distinctly does observation teach that subsequently to 
the first (or diarrhceal) stage the comparative value 
of different methods and individual medicines is very 
uncertain. . And, finally, it would seem that in this, as 
in other acute diseases, intelligent and careful nursing 
and regimen are quite as important as any medicinal 
treatment whatever. However a false notion of the 
power of medicine may blind us to the fact, it is none 
the less a fact, that if different methods of treatment 



1 36 CHOLERA. 

are compared, that method gives the best results 
which is least perturbative. For example, in Eng- 
land, on board of a hospital ship, were 85 cases, of 
which 19 treated by quinine gave 12 deaths, 12 by 
calomel gave 2 deaths, 12 by carbolic acid gave 3 
deaths, and 37 by " Nil " gave 1 death. 1 Or, again, 
in 1865, at the London Hospital, 159 patients were 
treated — 48 with a mixture containing logwood, ether, 
aromatic sulphuric acid, camphor, and capsicum, of 
whom 31 died; 56 with sweetened water, of whom 28 
died; 21 with castor oil, of whom 14 died; and 20 
with " saline lemonade," of whom 6 died. 2 In the last 
example the deaths during the use of the astringent 
mixture were twice as great as under sugar and water, 
and under castor oil twice as great as under " saline 
lemonade." 

We shall first give an account of the management 
of cholera in general, and then consider some of the 
particular medicines used in its treatment. 

The essential elements of all plans of treatment for 
this disease, as for so many others, are rest and absti- 
nence. Whatever else may be done, nothing avails 
without them. This remark applies emphatically to 
the premonitory diarrhoea ; if it is neglected it may 
readily be converted into the full-formed disease. It 
is therefore essential, during the prevalence of cholera, 
that whoever is attacked with diarrhoea should at once 
give up all active occupation, and confine himself to 
a recumbent posture and to the use of food of the 
blandest quality, such as mucilages and similar prepa- 

1 Times and Gaz., Dec, 1866, p. 590. 

2 London Hosp. Reports, Hi. 444. 



^ TREATMENT. 1 37 

rations, especially of rice, which, less than any other 
vegetable food, is liable to fermentation during diges- 
tion. It is prudent to drink no water that has not 
been boiled. If there is reason to believe that the 
bowels retain feces from before the attack, it is gener- 
ally thought advisable to administer a laxative dose 
of castor oil, to procure the discharge of matters which 
would act as irritants. Except for this purpose purga- 
tives are neither indicated nor expedient. . In a large 
number of cases nothing more is necessary than the 
use of means to check the action of the bowels, and 
which should consist of absorbents or antacids, astrin- 
gents, and opiates as they are contained in the officinal 
chalk mixture, with the addition of tincture of kino or 
catechu and a small proportion of laudanum. This 
medicine should be given in dessertspoonful doses at 
intervals of not more than an hour. 

If, instead of a diarrhoea which differs from ordinary 
dyspeptic diarrhoea chiefly by its watery character, 
there should also be colic and profuse discharges, it 
is proper to add to the medicines just suggested some 
which are of a decidedly stimulant character, such as 
the essential oils of cajeput, cloves, cinnamon, pepper- 
mint, etc., with which chloroform, ether, or Hoffman's 
anodyne may be associated. At the same time rube- 
facient embrocations may be applied to the abdomen, 
which should also be compressed slightly with a broad 
flannel bandage. Instead, of these stimulants, and per- 
haps more efficiently, may be used a simple epithem 
made by dipping a large towel several times folded in 
cold or cool water, applying it so as to cover the 

whole abdomen, and then enveloping it and the body 
12 * 



138 CHOLERA. 

with a dry towel. This application is more soothing 
than any liniment and its action is more constant. 
Instead of any of these agents dry heat may be used, 
obtained from bags of hot salt or sand, or moist heat 
from thick poultices of flaxseed meal or Indian corn 
meal or similar substances enclosed in flannel bags 
and applied to the abdomen while they are as hot as 
can be borne. It is difficult to determine which of 
these applications is the most useful. But, on the 
whole, heat is preferable to rubefacients, and moist to 
dry heat. The cold-water dressing is probably best 
suited to young and robust persons. 

It must be remembered that between choleraic diar- 
rhoea and cholera in its complete form there are sev- 
eral grades, in one of the most common of which a 
tendency to vomit, and even a certain amount of vom- 
iting, accompanies the diarrhoea. Anti-emetic rem- 
edies are then indicated. They may consist externally 
of rubefacient and aromatic applications to the epigas- 
trium (especially the spice poultice) ; and it is claimed 
that a hypodermic injection of morphia in this part is 
very efficient. Internally, the best remedies are ice 
swallowed in small pieces and small but frequent 
draughts of iced carbonated water or iced champagne. 
Where these liquids cannot be procured, effervescing 
powders used in the same way form a very good sub- 
stitute for them. If, notwithstanding such remedies, 
the diarrhoea continues or if it tends to increase, astrin- 
gent and absorbent medicines may be substituted for 
them ; for example, bismuth may be given instead of 
chalk, and if this also fails acetate of lead may be pre- 
scribed. The last may be used by the rectum as well 



TREATMENT. ■ 1 39 

as by the mouth, but with very questionable advantage. 
Meanwhile, especial care should be taken to avoid giv- 
ing so much of any opiate as will induce sopor or ex- 
cite nausea. 

Whoever has had the care of cholera patients has 
probably, at first, felt sanguine of success in their 
treatment, even after the characteristic discharges and 
the symptoms of collapse had set in ; but a little more 
experience has proved their hope to be deceptive, and 
revealed the reason of it in the absolute suspension of 
the sensibility and absorbent function of the digestive 
canal. Hence the dismal unanimity of all medical 
authors, who from actual observation of cholera have 
declared that no treatment avails to arrest the fully- 
developed disease. And yet there is some encourage- 
ment in the fact that recoveries sometimes occur from 
even the most desperate state of collapse and under 
the most dissimilar methods of treatment ; so that the 
physician is warranted in not yielding to discourage- 
ment and in cheering his patients with hope even to 
the end of life. The popular dread of this, and indeed 
of all epidemics, is sure to be exaggerated, and it there- 
fore behooves the physician to combat the fears of his 
patients, and by a cheerful manner as well as encourag- 
ing words administer the cordial of hope, which often 
proves stronger than pharmaceutic elixirs. 

It may be well to enumerate, as many do, the indi- 
cations of treatment in the active stage of cholera, but 
they really need no such specification. It is evident 
that they consist in combating the symptoms — the 
vomiting, the purging, the debility, the -cyanosis, the 
cramps, etc.; and the only means by which the carry- 



I40 CHOLERA. 

ing out of such indications can even be attempted are 
neither more nor less than would be used to relieve 
the same symptoms in other affections. If the evacua- 
tions could be controlled, evidently the cramps and the 
collapse would not occur; but this essential and pre- 
liminary step cannot be secured. The medicines intro- 
duced into the stomach or rectum are not absorbed, 
but are speedily rejected ; those which are administered 
subcutaneously are not taken up by the stagnant blood 
as freely as in other diseases ; the nervous system gives 
little or no response to the mechanical and physiolog- 
ical stimulants applied to the skin. Yet, in spite of 
these obstacles, the physician must persist in the use 
of rational methods, in the hope, however faint it may 
be, that he may succeed in restraining, and possibly in 
arresting, the fatal course of the attack. For this end 
he has hardly any means at command except those, or 
such as those, which were recommended in the first 
stage of the disease — the anti-emetic and anti-diar- 
rhceal medicines, which he is only too likely to see 
rejected as soon as administered. Yet he must not 
cease to allay the thirst by the repeated administration 
of small quantities of carbonated and cold liquids, 
water, or champagne wine, or morsels of ice swallowed 
whole. The application of pounded ice in a bladder 
to the epigastrium is a measure of an analogous sort, 
and is sometimes as efficient as generally it is soothing. 
In other cases the aromatic poultice seems to answer 
better. Of irritants little can be said that is favorable, 
but the combined irritant and anaesthetic action of 
chloroform is useful, and morphia should be applied to 
the epigastrium as well as given hypodermically. 



TREA TMENT. 1 4 1 

If the vomiting tends to become less frequent, acetate 
of lead may be prescribed, in the hope that it will exert 
some constringing action upon the gastro-intestinal 
mucous membrane. The distressing symptom, hic- 
cough, cannot with any certainty be controlled by 
medicine, but perhaps the inhalation of chloroform is 
more efficient than any other remedy, as it also is for the 
cramps in the limbs. For the latter purpose it is pref- 
erable to the frictions with flannel or with stimulating 
liniments which are generally employed. If such lini- 
ments are used, care should be taken that they do not 
contain ingredients that may disorganize the skin either 
immediately or subsequently. A dangerous compound 
of the latter sort introduced during the first epidemic 
of cholera in this country became officinal under the 
name of liniment of cantharides. 

The loss of the water and of the salts it holds in 
solution in the blood is, as has now been frequently 
repeated, the chief pathological element of the disease, 
next after the conjectural cause which injures the 
mucous membrane of the stomach and bowels. It 
was rationally indicated, and therefore a method was 
early practised, to supply this loss by injecting into 
the veins a solution of sodium salts. The method was 
seductive as well as rational, for its primary effects were 
extremely encouraging ; it nevertheless failed, and prob- 
ably for the very reason that suggested its use. In- 
deed, there is no more reason, if there is as much, to 
suppose that a liquid artificially introduced into the 
blood-vessels will be retained when the natural liquor 
sanguinis cannot be so. Necessarily, the one will es- 
cape where the other has escaped. 



142 CHOLERA. 

Certain systematic writers prescribe a method in- 
tended, on the one hand, for reviving the animal heat, 
and on the other for restoring the movement of the 
circulation. It need hardly be remarked that the two 
form essentially but one and the same indication. If 
the circulation is restored the animal heat will revive, 
but not otherwise. The same treatment leads to both 
ends, and it consists partly, as already stated, in the 
use of stimulants, such as alcohol, camphor, coffee, 
ether, etc. ; but their efficacy depends upon their being 
taken into the blood, and with it reaching the various 
nervous centres upon which the renewal of functional 
activity depends. Little, therefore, can be expected 
from them at the height of the disease — that is, in the 
stage of collapse — but as soon as any signs of reac- 
tion are manifested they tend to promote it, and hence 
may enable the functions to revive. For this reason 
they are adapted to persons who are feeble by reason 
of their tender or their advanced age, or who have 
previously suffered from ill-health. But if they act at 
all, and the more they tend to act, they must be em- 
ployed with circumspection, lest they outrun the pur- 
pose of their administration and produce a violent or 
excessive reaction. Instead of, or in conjunction with, 
these internal remedies the local stimulants of the 
skin, already enumerated, may be used with the due 
precautions, and, in addition, baths at a temperature of 
105 ° F. of water alone or with the addition of salt or 
mustard ; but all such remedies are of little avail until 
reaction has commenced. Before that event there is 
reason to believe that the cold bath is preferable, or, 
still better, frictions of the whole body with cold water, 



TREA TMENT. 1 43 

or even with ice, after which the patient should be 
wrapped in dry and warm blankets. Yet the efficacy 
of this powerful agency is by no means comparable to 
that which it produces in the algid forms of malarial 
fever. The two conditions, although apparently anal- 
ogous, are, in reality, very different. In the cold stage 
of fever the mechanism is indeed paralyzed, but none 
of its mechanical elements are wanting ; but in algid 
cholera there is an actual subtraction of water from 
the blood, that turns it from a liquid capable of cir- 
culating through the narrowest channels into one that 
stagnates even in the largest vessels. In the one case 
force is wanting to circulate the blood; in the other 
there is no normal blood to circulate. 

The treatment of the stage of reaction when it does 
not exceed a moderate degree, consists simply in 
strictly enforcing the rules for the patient's repose ; 
that is to say, in intelligent nursing. Mental excite- 
ment must be forbidden, and neither medicine nor food 
allowed that is likely to interfere with the gradual and 
steady progress of convalescence. Of all articles of 
food, cool water is not only the most urgently desired, 
but is the most imperatively necessary for replenishing 
the emptied blood-vessels and restoring the normal 
functions. But unless great caution is observed it will 
be taken too freely and provoke a renewal of the dis- 
charges. If any food besides water is allowed, it 
should be of the simplest sort — of whey first, and 
then of milk in small quantities at a time, with lime- 
water if it provokes nausea or retching. Afterward 
thin broths may be given, also in great moderation, 
and by degrees farinacea in milk and in animal broths. 



144 CHOLERA. 

Only when the strength is much improved should even 
the most digestible meats be permitted. In proportion 
as convalescence is marked or interrupted by symp- 
toms of undue reaction is it necessary to prolong and 
render stringent this regimen ; and if those symptoms 
unfortunately arise which oftener, perhaps, depend 
upon an over-zealous stimulant treatment than upon 
the natural reaction of the system, they must be com- 
bated by measures which will lessen the local conges- 
tions, especially of the brain and the lungs, and also 
by such as will tend to prevent the system from fall- 
ing into a typhoid state. For the former dry cups 
applied to the back of the neck, and cold lotions and 
affusions upon the scalp, are to be recommended, and 
for the latter dry cups and warm stimulating poultices 
upon the chest near the affected region. It is probable 
that the general warm bath, with cold affusion upon 
the head at the same time, would prove as efficient as 
it does in analogous states of typhoid affections. If 
the urinary secretion is suspended or remains scanty, 
there is not usually an urgent need of using means 
for its restoration ; for that will generally occur when 
the blood-vessels become replenished. It should, how- 
ever, be mentioned that, according to Macnamara, if 
the patient does not pass any urine within thirty-six 
hours of reaction coming on, ten minims of the tinc- 
ture of cantharides in an ounce of water should be 
given every half hour until six doses have been taken, 
and the patient encouraged to drink freely of water. 
If this treatment does not cause urine to pass, we 
must, after the sixth dose, discontinue the medicine 
for twelve hours, and then repeat it in precisely the 



TEE A TMENT. 1 4 5 

same way. The dose here referred to is of the British 
preparation, and if the use of it were not recommended 
by so competent an authority its propriety might very 
properly be challenged. 

After the cholera patient has become convalescent 
his restoration is very apt to be retarded by dyspeptic 
disorders, for which, perhaps, the best remedy is a ju- 
dicious use of condiments with the food and of bitter 
tonics, especially quinine, Colombo, quassia, etc. before 
meals. If there is constipation, it should be corrected 
by the cautious use of fruits, and, if these prove in- 
sufficient, of mild saline laxatives or small doses of 
castor oil or rhubarb. On the other hand, if there is 
a tendeney to diarrhoea, it should be met by the use 
of a mild laxative, such as castor oil, magnesia, or 
rhubarb, followed by chalk or bismuth, and the use 
for a time of simpler food and in less than the usual 
quantities. 

Having thus furnished a sketch of the plan of treat- 
ment of cholera which we regard as dictated by expe 
rience, it may be not without some interest to consider 
certain elements of the method a little more fully, and 
criticise, in passing, some other remedies which have 
from time to time been proposed. The first of these 
is venesection. There was a time when certain physi- 
cians, carried away by conceptions of the disease 
evolved from their inner consciousness, maintained 
that it consisted essentially of a spasm of the blood- 
vessels, and that the natural and legitimate cure for it 
was to be found in bleeding. No theory is so gratu- 
itous or absurd but cases may be found which appear 
to justify it, and in this instance also examples were 

13 



I46 CHOLERA. 

not wanting to illustrate at once the truth of the theory 
and its successful application. Longer experience, how- 
ever, and a more correct conception of the disease, have 
long since condemned this method, which was almost 
as dangerous as it was irrational. If any additional 
argument against it were required, it would be found 
in the condition of the lungs after death. These or- 
gans, we have seen, are not only not engorged, but 
they are empty of blood, and death is due not to 
asphyxia, but to apncea, when it takes place in col- 
lapse. 

If ever there existed any reason for the administra- 
tion of an emetic — and ipecacuanha has generally 
been used at the commencement of an attack of chol- 
era — it must be looked for, not in any clinical experi- 
ence of its virtues, but simply in the deplorable rou- 
tine that required the administration of an emetic at 
the commencement of nearly all acute diseases, so 
that, whatever else was prescribed, the lancet and an 
emetic seldom failed to be so. In this case also the 
proofs of the successful administration of ipecacuanha 
were not wanting, and one might be tempted to sup- 
pose, in view of the alleged facts in its favor, that it was 
useful by causing an evacuation of the material cause 
of the disease. In 1874, Surgeon Woodhull, U. S. 
Army, proposed for cholera the same treatment which 
had been found efficacious by East Indian practitioners 
in dysentery, and which has been imitated in many 
countries. It consists, essentially, of the administra- 
tion of a dose of from 20-40 drops of laudanum; or 
some equivalent dose of other liquid preparation of 
opium, followed in half an hour by from 20-60 grains 



TREA TMENT. 1 47 

of powdered ipecacuanha, the patient meanwhile being 
kept as still as possible in a recumbent posture. We 
cannot learn that the reasons which led to the intro- 
duction of this method have been justified by its suc- 
cess in practice. Physicians were even to be found, of 
high station and character, who contended that chol- 
era is a species of fever, and to be treated by an emeto- 
cathartic composed of tartar emetic and epsom salts. 
If the treatment had been efficient, the absurdity of the 
reasons for it might have been overlooked ; but the 
one was as disastrous as the other was false. But, as 
usual, the facts had been misstated or misinterpreted, 
and emetics ceased to form a part of the systematic 
treatment of cholera. The idea which possessed those 
who advocated the use of evacuants was that there 
was either a poison to be eliminated from the blood or 
one to be expelled from the bowels. Apparently, the 
method was not efficacious, for the latest phase of it, 
the use of castor oil in acute stage of cholera, was of 
short duration. 

When cholera first appeared in Europe the tendency 
naturally arose to follow in its treatment the example 
of the British practitioners in India. It then appeared 
that one of the most eminent among them, Annesley, 
gave a scruple of calomel, with two grains of opium, 
at the commencement of the attack, and repeated the 
dose in six or eight hours, and again upon the follow- 
ing day. In the decline of the disease he ordered 
scruple doses of calomel for the removal of a " cream- 
colored, thick, viscid, and tenacious matter exactly 
like old cream cheese, which glues the gut together 
and obstructs its passage." Three, four, and even five, 



148 CHOLERA. 

scruples of calomel were usually taken before this ef- 
fect was produced. When it is added that this practi- 
tioner held depletion to be the capital element of the 
treatment, and that he was equally lavish of his pa- 
tient's blood and of his own drugs, we can only won- 
der that any subjects of his heroic method survived. 
Even as late as 1885 it is certain that the delusion as 
to the action of calomel still survived. One physi- 
cian declared, " Whenever I have been able to get it 
to act on the liver I have had the satisfaction of seeing 
my patients recover." Evidently, he was not ac- 
quainted with the existing state of knowledge, which 
refuses to calomel all cholagogue power whatever. 
The practitioner here cited relates that in one case of 
cholera he gave fifty grains of calomel at once, and re- 
peated it " in equal or larger doses after every second 
or third evacuation. The patient eventually recovered." 
It is now conceded by all enlightened physicians that 
mercurials in large or in ordinary doses are worse than 
worthless in epidemic cholera. In 1832, Dr. Ayre of 
Hull, Eng., proposed another method of using calo- 
mel, to which he adhered in treating this disease. It 
consisted in the administration of very small doses of 
calomel at short intervals, and with each of the first 
doses a few drops of laudanum. Such a method, if 
not carried too far, certainly has the merit of sparing 
the patient a great deal of the perturbative treatment 
against which we have, in the preceding pages, pro- 
tested. But that was not at all the notion of its pro- 
poser. He claimed for it positive and active virtues. 
He stated, as the fundamental ground of his plan, that 



TREA TMENT. 1 49 

"the primary and leading object of the treatment must 
be to restore the secretion of the liver." He did not 
in the least doubt that he was able to do this by the 
administration of mercury — not, indeed, by a direct ac- 
tion upon the liver itself, but indirectly and sympa- 
thetically through the stomach, and by the healthy 
and specific stimulus imparted to it, by which the due 
secretion of the bile is promoted. It is, indeed, diffi- 
cult to conceive of any stimulus that calomel could 
impart to the stomach that would not be equally 
given by any other non-irritant and insoluble powder 
— subnitrate of bismuth, for example. Indeed, Ayre 
himself relates the case of a man who in an attack of 
cholera took during three days no less than five hun- 
dred and eighty grains of calomel, and recovered with- 
out any soreness of the mouth. But the plan which 
he finally elaborated was different. It was to give 
small doses of calomel repeatedly — in the premonitory 
stage one grain every half hour or hour for six or 
eight successive times, or, if this failed, every five or 
ten minutes — and in the stage of collapse one grain and 
a half every five minutes. In a few cases of extreme 
severity two grains of calomel were given every five 
minutes for an hour or two, and then the ordinary 
dose of one grain was resumed. But this was not all : 
with every dose of calomel was associated one, two, or 
three drops of laudanum, so that if these doses were 
repeated frequently the patient received a very efficient 
amount of the narcotic during the attack. Indeed, 
Ayre attributed to it the virtue of sustaining the vital 
powers under the depressing influence of the disease, 
and of removing or abating the cramps, as well as of 

13* 



150 CHOLERA. 

detaining the calomel in the stomach. 1 From the pre- 
ceding account it follows that the treatment of cholera 
by small doses of calomel with laudanum is founded 
on an erroneous assumption of the mode of action of 
calomel, and that whatever efficacy the plan of treat- 
ment may possess may with more justice be attributed 
to the opium, whose effects we know, than to the calo- 
mel, whose action, so far as it is known at all, has no 
conceivable relation to the disease for which it was 
given. However this may be, if the results of Ayre's 
treatment are compared with those of other plans, it 
exhibits very little if any superiority. In the report 
of the cholera committee of the College of Physicians, 
London, made in 1853, we find the statement that in 
725 unequivocal cases treated on Ayre's plan the 
deaths were 365, or about 50 per cent., and also the 
following commentary : " In general, no appreciable 
effects followed the administration of calomel, even 
after a large amount in small and frequently-repeated 
doses had been administered. For the most part, it 
was quickly evacuated by vomiting or purging, or, 
when retained for a longer period, was passed from the 
bowels unchanged. Salivation but very rarely oc- 
curred, and then only in the milder cases. We con- 
clude that calomel was inert when administered in col- 
lapse, and that the cases of recovery following its em- 
ployment at this period were due to the natural course 
of the disease, as they did not surpass the ordinary 
average obtained when the treatment consisted in the 
use of cold water only." 2 It is of interest to compare 

1 A Report on the Treatment of the Malignant Cholera, Lond., 
1833. 2 Dr. Gull's Report, p. 177. 



TREA TMENT. 1 5 I 

the mortality of 50 per cent, above stated to have oc- 
curred under this sort of calomel treatment with the 
mortality noted at the London Hospital under various 
kinds of treatment, including the administration of 
calomel in doses varying " from five to ten and twenty 
grains every quarter, half, one hour, two, four, etc." 
Out of 509 cases, 281 were fatal, or 54.9 per cent. 1 

Every disease in which exhaustion and coldness oc- 
cur is sure to be treated more or less actively with al- 
cohol, but in the collapse of cholera, as in the cold 
stage of fevers, it is generally useless, and sometimes 
hurtful. We believe that the following protest of 
Macnamara is sustained by almost universal experi- 
ence : " I would here enter an earnest protest against 
the use of brandy or any alcoholic stimulant in this 
[the second] stage of cholera. I believe these, both 
theoretically and practically, to be the cause of unmiti- 
gated evil. I simply, therefore, mention brandy, cham- 
pagne, and the like in order to condemn their use 
most emphatically in cholera ; according to my ideas 
and experience, it is almost impossible to hit on a 
more detrimental plan of treatment than that usually 
known as ' the stimulant ' in this form of disease." 2 
It is true that apparent dissidents from this judgment 
may be found, like Playfair, a deputy inspector of hos- 
pitals in Bengal, who even circulated printed direc- 
tions for the treatment of the first stage of the disease 
by means of brandy or strong rum, cayenne pepper, 
and laudanum, and had entire confidence in the effi- 
cacy of the method. 3 Dr. Macpherson, inspector- 

1 Lond. Hosp. Reports, iii. 437, 441. 2 Op. cif.,p. 456. 

3 Edinburgh Med. your., xix. 471. 



152 CHOLERA. 

general of hospitals, also, after comparing the results 
of a stimulant treatment with those of other methods, 
reaches the conclusion that the mortality-rate of chol- 
era is affected neither by the moderate nor by the ex- 
cessive use of alcohol. 1 

Dr. B. W. Richardson, whose judgments always 
carry weight with them, holds that no good whatever 
follows the use of alcohol in cholera, and that the local 
irritation it causes excites vomiting, induces febrile ex- 
citement, and favors after-prostration. He holds that 
creasote in small repeated doses, in combination with 
opium and camphor, checks the choleraic discharge, 
relieves the spasm, and " is the most demonstrably 
curative " of any remedy he has known. 2 Surgeon- 
General John Murray advocates the use of a five-grain 
pill containing one part of opium, two parts of asafcet- 
ida, and three parts of black pepper. 3 M. Cuneo, naval 
surgeon-in-chief at Toulon, suggests a mixture of ether, 
laudanum, and extract of rhatany in an aromatic ve- 
hicle. 4 

Upon no other point in the treatment of cholera is 
the agreement of physicians more complete than upon 
the use of opiates in the early stage of the disease. 
The premonitory diarrhoea has always been treated by 
opiates alone or associated with astringents. Probably 
the best rule is to give from twenty to thirty drops of 
laudanum, or an equivalent dose of some other liquid 
preparation of opium, in a little brandy and water, and 
repeat the dose as often as a stool is voided. Opiates 

1 Med. Times and Gaz., Jan., 1 870, p. 62. 

2 Ibid., Aug., 1883, p. 211. 8 Ibid., Aug., 1884, p. 254. 
* Bull, de therap., cvii. 56. 



TREATMENT. 153 

have also been generally employed to mitigate the 
symptoms of the fully- developed disease. But, like 
all other medicines introduced into the stomach or 
rectum, they are apt to be rejected, and even if they 
are not, their absorption is very doubtful, so that at 
the height of the attack they must be considered as 
nearly if not quite useless. When the vomiting and 
purging begin to subside and reaction is about to com- 
mence, small and repeated doses of opiates undoubt- 
edly tend to lessen the evacuations ; but great caution 
must be observed not to exceed the due degree of 
stimulation, lest a dangerous state of narcotism or 
collapse be induced. It might be supposed that the 
hypodermic use of morphia would be less open to 
objection than its administration by the stomach ; but 
it is to be remembered that the suspension of gastric 
absorption is only a part of the similar condition af- 
fecting the whole circulatory system, and that the stag- 
nation of the blood in the systemic veins prevents the 
absorption of medicines administered subcutaneously 
perhaps as completely as the state of the gastric blood- 
vessels interferes with their absorption from the stom- 
ach itself. In point of fact, the utility of opiates at 
any stage of cholera after the first is not easily deter- 
mined, for nearly always they are associated with other 
medicines, and especially with astringents. In this dis- 
ease, as in others that involve life, we are seldom at 
liberty to test the powers of individual medicines, but 
are bound to endeavor to save life by associating those 
which seem to be required for the purpose. Opiates, 
then, are nearly always given in conjunction with 
astringents or stimulants during the first (or diarrhceal) 



154 CHOLERA. 

stage of the attack, but after vomiting is added to diar- 
rhoea and a tendency to collapse is manifested they are 
at least useless. 

The patient, it has already been said, should be dis- 
turbed as little as possible, and hence, if he becomes 
restless, and especially if he is rendered so by pain, he 
should be tranquillized by means of anaesthetics. Chlo- 
roform has generally been employed, and is best ad- 
ministered on the first accession of cramps. Much 
pain, with muscular fatigue and depression, is thus 
saved, and the inhalation of the medicine may be re- 
peated as often as the pain threatens to return. No 
doubt other anaesthetics, .and especially ether, would 
answer the same purpose. 

Camphor has been claimed to be a valuable medi- 
cine in cholera, but there is no clinical evidence that it 
is so. Indeed, the only series of cases in which it was 
mainly depended upon gave a large mortality. 

Acids have been employed in cholera, but chiefly on 
theoretical grounds, " in the hope of destroying the 
specific cholera process going on in the intestinal 
canal " (Macnamara). It is hardly necessary to discuss 
so vague a reason. What specific process is going on? 
What relation to it has the administration of acids ? 
And, after all, only the hope is held out of destroying 
the hypothetical morbid process. The reaction of 
normal stools is usually acid, but sometimes it is 
neutral or even alkaline. In other acute bowel com- 
plaints with profuse diarrhoea they are acid, as in chol- 
era infantum, but in epidemic cholera they are alkaline, 
because they consist chiefly of the water of the blood. 
It is far from proven that mineral acids can be useful 



TREATMENT. ' 1 55 

merely by reversing the reaction of the stools. Far 
more probable is it that, in so far as they are of use, 
it is because they act as astringents upon the digestive 
mucous membrane. This may be inferred from the 
fact that, according to the advocates of these medi- 
cines, it is always difficult, and is often impossible, to 
acidify the stools in cholera. Moreover, it must be 
remembered that, like other medicines, the greater 
part of them are rejected by vomiting. If, then, 
mineral acids tend to lessen the diarrhcea of cholera, 
they act by their astringency and not by their acidity. 
Diluted or aromatic sulphuric acid may be given in 
the dose of from two to thirty minims, at intervals of 
an hour, in acid water or carbonated water, or diluted 
nitric acid, in doses of from twenty to fifty minims, at 
the same or somewhat longer intervals. 

Intravenous injections were used in England during 
the first epidemic of cholera in 1832—33, but their re- 
sults were regarded as unfavorable ; subsequently, in 
1849, they were tried with somewhat better success, 
and in 1867 the effects were still more encouraging. 
The liquid employed on the last-mentioned trial con- 
sisted of chloride of sodium 60 gr., chloride of potas- 
sium 6 gr., phosphate of sodium 3 gr., carbonate of 
sodium 20 gr., alcohol 2 drachms, and distilled water 
20 ounces. The alcohol was added only when the 
liquid was about to be used, and the temperature of 
the latter was not allowed to exceed no° F. or fall 
below ioo° F. The liquid was contained in a zinc 
vessel holding about eighty ounces, with a lamp un- 
derneath, a thermometer hanging within, and a tap 
near the bottom, from which proceeded an india-rub- 



156 CHOLERA. 

ber tube four feet long, with a silver nozzle at its end. 
The fluid was allowed to enter the vein by the force 
of gravity. If difficulty was experienced in introdu- 
ing the nozzle, the vein was freely exposed, supported 
on a probe, and incised longitudinally. It was found 
that the success of the operation depended greatly 
upon having an ample supply of the solution pre- 
pared, so as to repeat the injection as often as might 
be found necessary. Mr. Little, who practised this 
method in numerous cases, stated as follows : " When 
a patient has been long pulseless clots form in the 
heart, and, as I have seen, extend into the larger 
veins. In one case the fluid would not flow in, and 
only distended the veins of the arm injected. After 
death clots were found extending from the heart into 
the axillary vein." 1 Five out of twenty apparently 
hopeless cases recovered under this treatment. The 
first effect of the injection was to revive the pulse, 
which had ceased to be felt; the voice also was re- 
stored, the color and expression improved, the cramps 
were relieved, the temperature rose, and the patients 
became convinced that their recovery was assured. A 
profuse perspiration and a severe rigor accompanied 
these symptoms. The rigor was evidently a nervous 
phenomenon, and not a chill, for it occurred when the 
temperature was rising. Other cases might be cited 
which unquestionably owed their recovery to this 
mode of treatment. It is true, however, that much 
more frequently it failed of success ; and probably not 
only because the injection could not reach the heart, 
but because, having permeated the blood-vessels of 

1 London Hosp. Reports, iii. 470. 



TREATMENT. 1 57 

the whole body, it escaped, as the serum of the blood 
had done, from the damaged intestine. Nevertheless, 
it would seem that an expedient which in a certain 
proportion of cases has been quite successful might 
yet be rendered more certain in its results if the oper- 
ative procedure were perfected. Nicolas Duranty of 
Marseilles states that he fully employed this method, 
but unsuccessfully. 1 It is true that all of his patients 
were in the stage of collapse, and although in nearly 
all of them a decided improvement took place imme- 
diately after the injection, the fatal issue was not pre- 
vented. Hayem suggests the following as a suitable 
liquid for this purpose : 3^. Distilled water, I liter : 
pure chloride of sodium, 5 grams ; pure sulphate of 
sodium, 10 grams. Filter the solution, and heat it in 
a sand-bath to 1 00° F. The quantity for one injection 
is from two to two and a half liters, which is adminis- 
tered by degrees in the course often or fifteen minutes 
by means of a transfusion syringe. 2 According to 
Kronecker, 75 centigrams of pure chloride of sodium 
in 100 grams of water forms a solution of the proper 
strength. In a debate upon this subject in the Berlin 
Medical Society, Guttmann stated that he had made 
use of saline injections into the veins in 4 cases, all of 
which ended fatally. 3 In 1866, during an epidemic of 
cholera at Berlin, Fraenkel employed injections into 
the connective tissue of a solution of salt in water, but 
without the slightest advantage, 4 and probably without 
being acquainted with this record. In 1884, Dr. S. S. 

1 Bull, de ther., cvii. 247. 

2 Archives gen., Dec, 1884, p. 752. 

3 Bull, de therapy cvii. 476. 4 Ibid., cvii. 477. 

14 



1 5 8 CHOLERA. 

Todd l suggested a hypodermic injection of water to 
supply the intestinal waste. He proposed a solution 
containing a small quantity of chloride of sodium and 
chloride of potassium, and " such an amount of alcohol 
as may be deemed requisite." Just previously, Sam- 
uel had recommended multiple injections into various 
regions of the body, and during the whole of the stage 
of collapse, of solutions containing 6 grams of common 
salt and one gram of carbonate of sodium dissolved in 
IOOO grams of distilled water; 2 and about the same 
time Luton advocated a similar measure, and used a 
solution of sulphate of sodium of the strength of one- 
tenth, injecting deeply into the flesh of the buttocks 
about an ounce and a half of the solution at a time. 3 

Cramps in the limbs may be lessened by active fric- 
tion and shampooing, but there is no clinical reason for 
believing that these measures tend to restore the circu- 
lation. Equally ineffectual are other means used for 
communicating heat to the algid body and thereby 
reviving its functions. It is true that some physicians 
found that warm baths, at from 90 to 104 F., gave 
relief to the cramps and restored the failing pulse. In 
most cases the calming influence of the bath was noted, 
but it does not seem to have been curative or to have 
diminished the mortality-rate. 4 It should not be for- 
gotten that the patient has no perception of his cold- 
ness. In all analogous conditions, as has already been 
remarked, such as frostbite and the cold stage of peri- 
odical fevers, cold, and not heat, promotes reaction. 

1 your. Amer. Med. Assoc, 3, 152. 

2 Bull, de therap., cvii. 564. 3 Ibid., cvii. 124. 

4 London Hosp. Reports, iii. 445 ; St. Bartholomew's Reports, iii. 190. 



TREATMENT. 1 59 

Still more injurious, if possible, than hot applications 
are irritants and stimulants after the stage of collapse 
has set in. Not only are they absolutely futile for 
restoring the animal temperature, but they are liable, 
unless very cautiously used, to produce intractable 
sores upon the skin if recovery ensues. It should 
also be remembered that the cholera patient's exhaus- 
tion is exceptionally great, and is apt to be increased 
by the officiousness implied in the use of many stimu- 
lating agents. 

As early as 1832 a marked advantage was ascribed 
to the use of cold affusions in cholera. 1 One of the 
physicians of the cholera hospital of Berlin said : " In 
these living corpses which are struck with asphyxia, 
lying cold and powerless, external and internal medi- 
cines cease to stimulate ; no steam apparatus, no warm 
bathing, no friction, no irritant, avails." The condition 
is comparable to that in approaching death by cold, in 
which friction with snow is well known to be the proper 
remedy. Cold affusions were employed in the second 
stage of the disease. If the pulse revived, the affu- 
sions were continued in a tepid bath, after which the 
patient was put to bed and gently rubbed with cold 
flannels. Internally, ice-water was freely administered. 
Labadie-Lagrave 2 refers to forty cases treated in this 
manner, with only seven deaths. Yet the cold-water 
treatment does not appear to have commended itself 
to physicians generally. Evidently it does not meet 
the prime indication, which is to restore the wasted 
waters of the blood and retain it in the blood-vessels. 

1 Ainsworth, Pestilential Cholera, 1 83 2. 

2 Du Froid en Therapeutique, 1878. 



l6o CHOLERA. 

Cold water ought to be given freely, but in small 
quantities at a time, to assuage the thirst that exists in 
every stage of cholera, and especially in collapse. Nor 
should it be withheld because it will presently be re- 
jected, for not only does it produce a grateful sensa- 
tion in the mouth and throat, but it renders the act of 
vomiting easier. Yet, to some extent at least, the thirst 
may be allayed by rinsing the mouth and throat with 
cold water. Iced water is preferable to ice used for 
the same purpose, for the latter, by its relatively intense 
coldness, irritates and dries the mouth. Fragments of 
ice swallowed whole allay the burning heat in the 
stomach. 

On the hypothesis that the cholera poison consists 
of organic germs various antiseptics have been em- 
ployed in this disease. Permanganate of potassium 
was fortunately excluded from the list, on account of 
its corrosive action, but, unfortunately, carbolic acid 
was conceived to possess virtues that rendered it an 
eminently suitable remedy, and creasote, which resem- 
bles it very closely,was presumed to possess correspond- 
ing virtues.. Then sulphurous acid and the sulphites, 
which for a time were warranted to destroy every 
species of germ, were confidently appealed to to stay 
the progress of cholera, and it was at one time even a 
matter of dispute whether sulphite of sodium or sul- 
phite of potassium was the more efficacious. In 
truth, all of these medicines were useless, even when 
they were not mischievous. It may be mentioned, 
in conclusion, that some physicians have alleged that 
the inhalation of oxygen gas is beneficial in this 
disease. 



TREATMENT. l6l 

Cholera has never prevailed in any country without 
giving rise to extraordinary theoretical and practical 
divagations. One physician in the earliest American 
epidemic gravely proposed, as the best mode of check- 
ing the diarrhoea, to plug the anus with a soft velvet 
cork. Recently, French and also Italian physicians 
have discovered that astringents, and especially tannin, 
are the proper and physiological antidotes to the disease. 
An English practitioner suggested that the " blood 
may be kept circulating by putting the patient on his 
back on a board and keeping up a rocking, see-saw, 
to-and-fro movement from eighty to one hundred times 
a minute." Another had the revelation that the dis- 
ease is essentially a " paralysis of the sympathetic nerve 
and want of performance of the organic functions, with 
deficient vitality of the mucous membranes," and that 
its proper remedies are "bleeding, turpentine, and cool 
drinks, without heat and stimulants ; " and to this re- 
markable doctrine a well-known physician gives his ad- 
hesion, thus : " The cause, I firmly believe, is an union 
of the poison with the sympathetic." 1 Still another 
discovered that the disease is a spinal disorder, and 
is to be treated by the application of ice-bags to the 
spine. Were not the evidence so palpable, it would 
hardly be believed that such irrational ideas should 
have been published concerning a disease which had 
then been under observation by the whole medical pro- 
fession in Europe and America for more than thirty 
years, and in Asia for a much longer period. 

The most important lesson to be- drawn from this 
history of the treatment of epidemic cholera is, that the 

1 Times and Gazette, Aug., 1866, p. 209; ibid., Nov., 1866, p. 555. 
14* 



1 62 CHOLERA. 

arrest of the disease in the diarrhceal stage is compara- 
tively easy, and that in the stage of collapse its cure by 
any means whatever is altogether an exceptional oc- 
currence. 

May 1 8, 1885, the following telegrams were published 
in the daily newspapers : " Madrid, May 16. — Over 
4700 persons have been inoculated with cholera mi- 
crobes by Dr. Ferran, in the province of Valencia, as 
a preventive of the disease. The new system is said 
to be entirely successful, and the epidemic is disappear- 
ing. Dr. Ferran intends to visit England in a few 
weeks." " London, May 17. — The Government will 
send a medical mission to Spain to test the results of 
the system of inoculation with cholera microbes." 

If the doctrine which has been maintained in this 
essay as the true explanation of the phenomena of 
cholera and the results of its treatment be correct, it 
follows that the alleged results of cholera inoculation 
are deceptive and erroneous. To assume that cholera 
bacilli introduced into the blood can have any influence 
in preventing the action of the cholera poison upon 
the stomach and bowels is unscientific and illogical. 
For if there is one fact settled in the pathology, of 
cholera, it is that its specific germ acts primarily and 
chiefly upon the gastro-intestinal mucous membrane ; 
and hence that the symptoms of the disease are all of 
them due to that action as their primary cause. 



INDEX. 



ABDOMEN, 80 
Abdominal lessions, 95 
Acids, 154 
Affusions, 159 
Alcohol, in treatment of cholera, 

151 

Anatomy, morbid, 81 

Anti-emetics, 138 

Antiseptics, 1 60 

Asiatic cholera, history, 15 

Astringents and antacids, 157 

Atmosphere, as a vehicle of con- 
tagion, 37 

Ayre's method of using mercurials, 
148 

BACILLI, recent observations, 
90-95 ; 104 ; former views 
of, 101 
Bacteria, treatment based on the- 
ory of, 132 
Baths, 142; 158 
Blood, lesions of, 98 
Brain, lesions of, 97 

CADAVERIC rigidity, 82 
Camphor, 154 

Causes, ^^ 

Chloroform, 154 

Cholera, Asiatic, history, 15 ; intro- 
duction into America, 19; in 
1830-32, 19; in 1853, 23; in 
1864-66, 24; in 1873, 2 5 ; m 
1881-83, 26-28; in China, 17; 
26; in France, 1884, 29-32; in 



New Orleans, 1832, 23; in New 
York, 1832, 21; progress of, 18 

Cholera morbus, diagnosis from, 
108 ; of ancients, 14 

Circulation, 73 

Climate and season, influence of, 

35 

Clothing, soiled, a vehicle of chol- 
era, 51 
Cold, applied to spine, 161 
Cold water, 159 
Complications, 68 
Contagiousness of cholera, 53—59 
Convalescence, 67, 68 
Cramps, 79 

DIAGNOSIS, 106; from cholera 
morbus, 107 
Definition of cholera, 14 
Diarrhoea, 76 
Diet, 136 
Disinfectants, 125 
Drinks, cool, 160 

ERUPTIONS, 72 
Extension of cholera, man- 
ner of, 34 

FILTH, dampness, crowding, as 
causes, 38 
Fomites of cholera, 40 
Forms, grave, 64; intermediate, 

63 ; mild, 61 • 
Friction, shampooing, etc., 158 
163 



164 



INDEX. 



HABITS of living, 36; 39 
Heart, action of, in cholera, 
72; lesions of, 98 
History, 14 

INOCULATION, 162 
1 Ipecacuanha, 146 

KIDNEYS, lesions of, 96 
Klein and Gibbes, on bacilli, 
92 
Koch, on bacilli, 90; 104; 105 

LESIONS of intestine, 86-90; 
of stomach, 85 
Lewis, on bacilli, 94 
Lungs, lesions of, 97 

MERCURY, 147 
Mortality, 114 
Muscular action post-mortem, 82- 
84 







PIUM, 152 



PATHOLOGY, 81 
Prevention, 117 
Prognosis, 1 13 

Prussian rules to limit cholera, 126 
Physicians, liability of, to cholera, 

53.54 
Pulse, 72 

QUARANTINE, 117; Interna- 
tional Medical Congress of 
1874 on, 121; modified, 123; 
efficacy of, 122 



"DATIONALE of cholera, 100 ; 

IV 103 



SANITARY regulations, 124; in 
Prussia, 126 
Sequelae, 68 
Sleep; mental state, 8 1 
Stages, 61-68 

Stimulants, 137; 142; 151 
Stools, 77 

Strauss, on bacilli, 94; 103 
Symptomatology, 60 
Symptoms, special, 69 
Synonyms, 14 

TEMPERATURE, 70 
Treatment, 131 ; antizymotic, 
132 ; comparative results of, 136 ; 
governed by grade of attack, 134 ; 
eccentric methods of, 161 ; of 
convalescence, 144; of reaction, 
143; systematic, 136 



u 



RINE, 78 



T7EINS, saline injections into, 

* Hi. 155 

Venesection, 145 

Vomiting, 74; treatment of, 138; 
140; 141 



WARM BATHS, 158 
Water as a vehicle of chol- 
era, 40-50; importance of using 
pure, 131 



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